Pharmaceutical compositions

ABSTRACT

The invention relates to pharmaceutical compositions comprising PPAR agonists and Nrf2 activators and methods of using combinations of PPAR agonists and Nrf2 activators for treating diseases such as psoriasis, asthma, multiple sclerosis, inflammatory bowel disease, and arthritis.

CROSS-REFERENCE TO RELATED APPLICATIONS

This application is a divisional of U.S. Ser. No. 13/654,632, filed Oct.18, 2012, which claims the benefit of U.S. Provisional Application Ser.No. 61/663,761, filed Jun. 25, 2012, the disclosure of which is herebyincorporated by reference in its entirety, including all figures, tablesand amino acid or nucleic acid sequences.

Disclosed herein are pharmaceutical compositions comprising pparagonists and Nrf2 activators (each an “agent” and together “agents”),and methods of using combinations of ppar agonists and Nrf2 activatorsfor treating diseases such as psoriasis, asthma, multiple sclerosis,inflammatory bowel disease, and arthritis.

Perixome Proliferator Activated Receptors (PPARs) activate transcriptionby binding to elements of DNA sequences, known as peroxisomeproliferator response elements (PPRE), in the form of a heterodimer withretinoid X receptors (known as RXRs). Three subtypes of human PPARs havebeen identified and described: PPARα, PPARγ (PPAR gamma) and PPARδ (orNUC1). PPARα is mainly expressed in the liver, while PPARδ isubiquitous. PPARγ is the most extensively studied of the three subtypes.See e.g. “Differential Expression of Peroxisome Proliferator-ActivatedReceptor Subtypes During the Differentiation of Human Keratinocytes”,Michel Rivier et al., J. Invest. Dermatol., 111, 1998, pp. 1116-1121, inwhich is listed a large number of bibliographic references relating toreceptors of PPAR type. Mention may also be made of the report entitled“The PPARs: From orphan receptors to Drug Discovery”, Timothy M.Willson, Peter J. Brown, Daniel D. Sternbach and Brad R. Henke, J. Med.Chem., 2000, Vol. 43, pp. 527-550. It is suggested that PPARγ play acritical role in regulating the differentiation of adipocytes, where itis greatly expressed. It also has a key role in systemic lipidhomeostasis.

It has been reported that the thiazolidinedione class of compounds (thegroup of so-called glitazones) including rosiglitazone, rosiglitazonemaleate, pioglitazone, pioglitazone hydrochloride, troglitazone andciglitazone and or its salt forms are potent and selective activators ofPPAR-gamma (so-called PPAR gamma agonists) and bind directly to thePPAR-gamma receptor (J. M. Lehmann et al., J. Biol. Chem. 12953-12956,270 (1995)), providing evidence that PPAR-gamma is a possible target forthe therapeutic actions of the thiazolidinediones. Since thisobservation, activation of this nuclear hormone receptor has been shownto have pleiotropic metabolic and nonhypoglycemic effects. Clinical useof the agents in the treatment of Type 2 diabetes mellitus (or noninsulin dependent diabetes mellitus (NIDDM)) is associated withsensitization to the glucose lowering effects of insulin as well aspotentiation of other biological actions of insulin in target tissues.When used as monotherapy, there are reports of fluid retention resultingin volume expansion and, in some patients, clinical edema. The incidenceof edema appears to be increased when both these agents are used incombination with insulin (Nesto R. W. et al, 2003, Circulation, 108,2941-2948). However, the mechanisms involved in these effects have notbeen well described but the nature of the presentation suggests anintegrated physiological response which includes an effect on renal saltand water balance. PPAR gamma receptors have been found in the renalcollecting duct (Guan Y. et al; 2001, Kidney Int. 60, 14-30) and,therefore, the PPAR gamma agonists might be involved directly in renaltubular metabolism or could have secondary effects on salt and waterhomeostasis. The ppar gamma agonist pioglitazone has been suggested as atreatment of psoriasis in e.g. British Journal of Dermatology 2005 152,pp 176-198.

Nuclear factor erythroid-2 related factor 2 or Nuclear FactorE2p45-Related Factor (Nrf2) is a cap-and-collar basic leucine zippertranscription factor, regulates a transcriptional program that maintainscellular redox homeostasis and protects cells from oxidative insult(Rangasamy T, et al., J Clin Invest 114, 1248 (2004); Thimmulappa R K,et al. Cancer Res 62, 5196 (2002); So H S, et al. Cell Death Differ(2006)). NRF2 activates transcription of its target genes throughbinding specifically to the antioxidant-response element (ARE) found inthose gene promoters. The NRF2-regulated transcriptional programincludes a broad spectrum of genes, including antioxidants, such asγ-glutamyl cysteine synthetase modifier subunit (GCLm), γ-glutamylcysteine synthetase catalytic subunit (GCLc), heme oxygenase-1,superoxide dismutase, glutathione reductase (GSR), glutathioneperoxidase, thioredoxin, thioredoxin reductase, peroxiredoxins (PRDX),cysteine/glutamate transporter (SLC7A11) (7, 8)], phase IIdetoxification enzymes [NADP(H) quinone oxidoreductase 1 (NQO1), GST,UDP-glucuronosyltransferase (Rangasamy T, et al. J Clin Invest 114: 1248(2004); Thimmulappa R K, et al. Cancer Res 62: 5196 (2002)), and severalATP-dependent drug efflux pumps, including MRP1, MRP2 (Hayashi A, et al.Biochem Biophy Res Commun 310: 824 (2003)); Vollrath V, et al. Biochem J(2006)); Nguyen T, et al. Annu Rev Pharmacol Toxicol 43: 233 (2003)).

Interlinked with Nrf2 is KEAP1, which is a cytoplasmic anchor of Nrf2that also functions as a substrate adaptor protein for a Cul3-dependentE3 ubiquitin ligase complex to maintain steady-state levels of NRF2 andNRF2-dependent transcription (Kobayashi et al., Mol Cell Biol 24: 7130(2004); Zhang D, et al. Mol Cell Biol 24: 10491 (2004)). The Keap 1 geneis located at human chromosomal locus 19p13.2. The KEAP1 polypeptide hasthree major domains: (1) an N-terminal Broad complex, Tramtrack, andBric-a-brac (BTB) domain; (2) a central intervening region (IVR); and(3) a series of six C-terminal Kelch repeats (Adams J, et al. TrendsCell Biol 10:17 (2000)). The Kelch repeats of KEAP1 bind the Neh2 domainof Nrf2, whereas the IVR and BTB domains are required for theredox-sensitive regulation of Nrf2 through a series of reactivecysteines present throughout this region (Wakabayashi N, et al. ProcNatl Acad Sci USA 101: 2040 (2004)). KEAP1 constitutively suppressesNrf2 activity in the absence of stress. Oxidants, xenobiotics andelectrophiles hamper KEAP 1-mediated proteasomal degradation of Nrf2,which results in increased nuclear accumulation and, in turn, thetranscriptional induction of target genes that ensure cell survival(Wakabayashi N, et al. Nat. Genet. 35: 238 (2003)). Prothymosin α, anovel binding partner of KEAP1, has been shown to be an intranucleardissociator of NRF2-KEAP1 complex and can upregulate the expression ofNrf2 target genes (Karapetian R N, et al. Mol Cell Biol 25: 1089(2005)). Certain interactions between Nrf2 and ppar gamma have beensuggested, e.g. Am J Respir Crit. Care Med 2010; 182:170-182.

Nrf2 activators according to the present invention are agents that afteradministration result in a stimulated and/or increased nucleartranslocation of Nrf2 protein and causes the subsequent increases ingene products that detoxify and eliminate cytotoxic metabolites. Nrf2activators according to the present invention may act directly on Nrf2,KEAP1, the NRF2-KEAP1 complex and/or otherwise. Nrf2 activators of thepresent invention may comprise a Michael addition acceptor, one or morefumaric acid esters, i.e. fumaric acid mono- and/or diesters which arepreferably selected from the group of monoalkyl hydrogen fumarate anddialkyl fumarate, such as monomethyl hydrogen fumarate, dimethylfumarate, monoethyl hydrogen fumarate, and diethyl fumarate, furthermoreethacrynic acid, bardoxolone methyl (methyl2-cyano-3,12-dioxooleana-1,9(11)dien-28-oate), isothiocyanate such assulforaphane, 1,2-dithiole-3-thione such as oltipraz,3,5-di-tert-butyl-4-hydroxytoluene, 3-hydroxycoumarin, or apharmacologically active derivative or analog of the aforementionedagents.

Very preferred Nrf2 activators for use in combination with PPAR gammaagonists according to the present invention are bardoxolone methyl andfumaric acid esters.

Fumaric acid esters are approved in Germany for the treatment ofpsoriasis, are being evaluated in the United States for the treatment ofpsoriasis and multiple sclerosis, and have been proposed for use intreating a wide range of immunological, autoimmune, and inflammatorydiseases and conditions. FAEs and other fumaric acid derivatives havebeen proposed for use in treating a wide-variety of diseases andconditions involving immunological, autoimmune, and/or inflammatoryprocesses including psoriasis (Joshi and Strebel, WO 1999/49858; U.S.Pat. No. 6,277,882; Mrowietz and Asadullah, Trends MoI Med 2005, 111(1),43-48; and Yazdi and Mrowietz, Clinics Dermatology 2008, 26, 522-526);asthma and chronic obstructive pulmonary diseases (Joshi et al., WO2005/023241 and US 2007/0027076); cardiac insufficiency including leftventricular insufficiency, myocardial infarction and angina pectoris(Joshi et al., WO 2005/023241; Joshi et al., US 2007/0027076);mitochondrial and neurodegenerative diseases such as Parkinson'sdisease, Alzheimer's disease, Huntington's disease, retinopathiapigmentosa and mitochondrial encephalomyopathy (Joshi and Strebel, WO2002/055063, US 2006/0205659, U.S. Pat. No. 6,509,376, U.S. Pat. No.6,858,750, and U.S. Pat. No. 7,157,423); transplantation (Joshi andStrebel, WO 2002/055063, US 2006/0205659, U.S. Pat. No. 6,359,003, U.S.Pat. No. 6,509,376, and U.S. Pat. No. 7,157,423; and Lehmann et al, ArchDermatol Res 2002, 294, 399-404); autoimmune diseases (Joshi andStrebel, WO 2002/055063, U.S. Pat. No. 6,509,376, U.S. Pat. No.7,157,423, and US 2006/0205659) including multiple sclerosis (MS) (Joshiand Strebel, WO 1998/52549 and U.S. Pat. No. 6,436,992; Went andLieberburg, US 2008/0089896; Schimrigk et al., Eur J Neurology 2006, 13,604-610; and Schilling et al., Clin Experimental Immunology 2006, 145,101-107); ischemia and reperfusion injury (Joshi et al., US2007/0027076); AGE-induced genome damage (Heidland, WO 2005/027899);inflammatory bowel diseases such as Crohn's disease and ulcerativecolitis; arthritis; and others (Nilsson et al., WO 2006/037342 andNilsson and Muller, WO 2007/042034). All these indications and diseasescan be treated or prevented with the combination treatment of thepresent invention.

Fumaderm®, an enteric coated tablet containing a salt mixture ofmonoethyl fumarate and dimethylfumarate, which is rapidly hydrolyzed tomonomethyl fumarate, was approved in Germany in 1994 for the treatmentof psoriasis. Fumaderm® is dosed TID with 1-2 grams/day administered forthe treatment of psoriasis.

Fumaric acid derivatives (Joshi and Strebel, WO 2002/055063, US2006/0205659, and U.S. Pat. No. 7,157,423 (amide compounds andprotein-fumarate conjugates); Joshi et al., WO 2002/055066 and Joshi andStrebel, U.S. Pat. No. 6,355,676 (mono and dialkyl esters); Joshi andStrebel, WO 2003/087174 (carbocyclic and oxacarbocylic compounds); Joshiet al., WO 2006/122652 (thiosuccinates); Joshi et al., US 2008/0233185(dialkyl and diaryl esters) and salts (Nilsson et al., US 2008/0004344)have been developed in an effort to overcome the deficiencies of currenttherapy with fumaric acid esters. Controlled release pharmaceuticalcompositions comprising fumaric acid esters are disclosed by Nilsson andWiller, WO 2007/042034. Prodrugs are described by Nielsen and Bundgaard,J Pharm Sci 1988, 77(4), 285-298 and in WO2010/022177.

DETAILED DESCRIPTION

Preferably, the term “alkyl” is specifically intended to include groupshaving any degree or level of saturation, i.e., groups havingexclusively single carbon-carbon bonds, groups having one or more doublecarbon-carbon bonds, groups having one or more triple carbon-carbonbonds, and groups having combinations of single, double, and triplecarbon-carbon bonds. Where a specific level of saturation is intended,the terms alkanyl, alkenyl, and alkynyl are used. In certainembodiments, an alkyl group can have from 1 to 20 carbon atoms (Ci-20)in certain embodiments, from 1 to 10 carbon atoms (Ci-I0), in certainembodiments from 1 to 8 carbon atoms (C]-8), in certain embodiments,from 1 to 6 carbon atoms (C1-6), in certain embodiments from 1 to 4carbon atoms (C1-4), and in certain embodiments, from 1 to 3 carbonatoms (Ci-3). The term “alkoxy” refers to a group O-alkyl, wherein alkylhas the meaning indicated above. The term “perfluoroalkyl” refers to analkyl group wherein all hydrogen atoms have been replaced by fluoro.

“Treating” or “treatment” of any disease refers to reversing,alleviating, arresting, or ameliorating a disease or at least one of theclinical symptoms of a disease, reducing the risk of acquiring a diseaseor at least one of the clinical symptoms of a disease, inhibiting theprogress of a disease or at least one of the clinical symptoms of thedisease or reducing the risk of developing a disease or at least one ofthe clinical symptoms of a disease. “Treating” or “treatment” alsorefers to inhibiting the disease, either physically, (e.g.,stabilization of a discernible symptom), physiologically, (e.g.,stabilization of a physical parameter), or both, and to inhibiting atleast one physical parameter that may or may not be discernible to thepatient. In certain embodiments, “treating” or “treatment” refers todelaying the onset of the disease or at least one or more symptomsthereof in a patient which may be exposed to or predisposed to a diseaseeven though that patient does not yet experience or display symptoms ofthe disease.

“Therapeutically effective amount” refers to the amount of a compoundthat, when administered to a subject for treating a disease, or at leastone of the clinical symptoms of a disease, is sufficient to affect suchtreatment of the disease or symptom thereof. The “therapeuticallyeffective amount” may vary depending, for example, on the compound, thedisease and/or symptoms of the disease, severity of the disease and/orsymptoms of the disease or disorder, the age, weight, and/or health ofthe patient to be treated, and the judgment of the prescribingphysician. An appropriate amount in any given instance may beascertained by those skilled in the art or capable of determination byroutine experimentation.

“Therapeutically effective dose” refers to a dose that provideseffective treatment of a disease or disorder in a patient. Atherapeutically effective dose may vary from compound to compound, andfrom patient to patient, and may depend upon factors such as thecondition of the patient and the route of delivery. A therapeuticallyeffective dose may be determined in accordance with routinepharmacological procedures known to those skilled in the art.

Reference is now made in detail to certain embodiments of compounds,compositions, and methods. The disclosed embodiments are not intended tobe limiting of the claims.

According to the present invention, strongly improved treatment resultsare obtained in the treatment of autoimmune and/or inflammatorydiseases, when a ppar agonist and preferably a ppar gamma agonist and anNrf2 activator are used in the treatment of the disease in combinationas compared to the treatment with a ppar gamma agonist or an Nrf2activator, alone. Co-administration of a ppar gamma agonist and an Nrf2activator or an administration of a fixed dose combination of a PPARgamma agonists and an Nrf2 activator results in an improved therapeuticeffect, which may be a more than additive effect, compared to theadministration of a PPAR gamma agonist or Nrf2 activators, respectively,administered as mono-therapy.

In particular, it has been found that the advantageous therapeuticresults in inflammatory and/or autoimmune diseases resulting from use ofcompounds such as dexamethasone, having both ppar gamma agonistic andNrf2 activating effects, can be matched or even surpassed by thecombination treatment of the present invention, wherein at least twoindividual and different compounds having each either PPAR gammaagonistic or Nrf2 activating effects, are employed. Thus, a combinationtreatment comprising at least one PPAR gamma agonist, which may have nosignificant or only a minor modulating or activating effect on Nrf2, andat least one Nrf2, which may have no significant or only a minormodulating or activating effect on ppar gamma, result in improved andsynergistic therapeutic effects, as compared to the administration ofsuch PPAR gamma agonist or such Nrf2 activator, respectively,administered as mono-therapy. The synergistic effect is often morepronounced with such combinations, where the agents employed arepredominantly either PPAR gamma agonists or Nrf2 activators, which eachhave no significant activity on the respective other target.Nevertheless, even in those cases where one or both of the agentsdisplay significant PPAR gamma agonistic and Nrf2 activating effects atthe same time, such as in the case of dexamethasone and15-deoxy-delta(12,14)-prostaglandin J(2) (15d-PGJ(2)), the combinationtreatment according to the present invention can lead to improvedtreatment results over the mono-therapy. A compound having dual effectson the targets PPAR gamma and Nrf2, is unlikely to show an ideallydistributed effect on both targets for therapeutic use. By applying thepresent invention each target can be addressed individually andactivated with suitable and appropriate concentrations of the respectiveagents.

Thus, embodiments are preferred, wherein at least one agent is not both,PPAR gamma agonist and Nrf2 activator at the same time.

Combination treatments and fixed dose combinations according to thepresent invention are preferred, which comprise at least two differentagents having either PPAR gamma agonistic or Nrf2 activating effects atthe concentration used in the combination.

The present invention relates to combination treatments, compositionscontaining the inventive combination of agents and related fixed-dosecombinations, wherein the ppar agonist, such as the ppar gamma agonistand the Nrf2 activator are different compounds which are preferably notbelonging to the same chemical class. Throughout this specification, theuse of a singular includes also the plural, if not indicated otherwise.

Preferred PPAR agonists are compounds having a PPAR gamma agonisticeffect without significantly activating Nrf2. These are preferablycompounds having no ability to form covalent bonds with organic thiolgroups under physiological conditions, such as with glutathione. Thus,preferred PPAR gamma agonists are compounds that, contrary to e.g.15-deoxy-delta(12,14)-prostaglandin J(2) (15d-PGJ(2)), cannot bindcovalently through e.g. Michael addition reaction to the PPA receptor.Most preferred PPAR agonists are glitazones, glitazars and sartans.

Ppar agonists are ppar activators (e.g., ppar gamma agonist are ppargamma activators). The definition “ppar agonist” and “ppar gammaagonist” according to the present invention preferably includes suchagonists, i.e., compounds, that directly bind to the ppa receptor andhave an agonistic, i.e. activating effect, as well as so-calledphysiological ppar agonists and physiological ppar gamma agonists, whichdo not necessarily bind to the ppar receptor, but result in anactivation of ppar through other pathways, such as by increasing theconcentration of endogenous ppar gamma agonist15-deoxy-Delta(12,14)-prostaglandin J(2) (15d-PGJ(2).

A large number of natural and synthetic PPAR agonists are known (e.g.see Michalik et al. (2006) Pharmacological Reviews 58:726-725; Gilde etal. (2003) Circulation Research 92(5): δ 18-524; Peraza et al. (2005)Toxicological Sciences 90(2):269-295; and Desvergne & Wahli (1999)Endocrine Reviews 20(5):649-688). Some of these known agonists arespecific for a single PPAR isotype, whilst others target multiple PPARsubtypes. PPAR agonists are preferred, if the ppar agonist strongeractivate ppar gamma or ppar gamma and ppar alpha simultaneously, thanother isoforms.

In one embodiment, the ppar agonist may be selected from the groupconsisting of ppar gamma agonists, such as glitazones and dual pparalpha/gamma agonists, such as glitazars. In yet further embodiments, theglitazone may be selected from the group consisting of troglitazone,pioglitazone, rosiglitazone, ciglitazone, englitazone, darglitazone,netoglitazone, isaglitazone, MC-555, balaglitazone, rivoglitazone, andthe like. In yet further embodiments, the glitazar may be selected fromthe group consisting of muraglitazar, naveglitazar, tesaglitazar,ragaglitazar, reglitazar and farglitazar. In yet further embodiments,ppar agonists are selected from berberine, K-111, INT-131, MBX-102(metaglidisen), MBX-2044, FK614, GSK-376501, GW 1929, S26948,psi-baptigenin and the like, such as those disclosed in US5002953,US4687777 and US5965584. Pioglitazone and rosiglitazone are verypreferred and most preferred are pioglitazone hydrochloride androsiglitazone maleate.

In a further preferred embodiment of the present inventions, ppar gammaagonists are selected from the class of statins or HMG-CoA reductaseinhibitors, preferably selected from atorvastatin, fluvastatin,lovastatin, pravastatin, rosuvastatin, simvastatin, mevastatin andpitavastatin. Statins are a class of drugs used to lower cholesterollevels by inhibiting the enzyme HMG-CoA reductase, which plays a centralrole in the production of cholesterol in the liver. Increasedcholesterol levels have been associated with cardiovascular diseases,and statins are therefore used in the prevention of these diseases.Statins have also been suggested for the treatment of multiple sclerosis(e.g. US 2004/0013643). Although statins are believed to activate ppargamma only indirectly (Circ Res. 2007; 100:1442-1451), as physiologicalppar gamma agonists they are included in the definition of ppar gammaagonists for the purposes of the present invention.

In a further preferred embodiment of the present inventions, ppar gammaagonists are selected from the chemical classes of sartans, also knownas angiotensin II receptor antagonists, angiotensin receptor blockers(ARBs) or AT1-receptor antagonists. Sartans, such as valsartan,losartan, azilsartan, irbesartan, olmesartan, telmisartan, candesartanand eprosartan are a group of pharmaceuticals which modulate therenin-angiotensin-aldosterone system. Preferred sartans used in thepresent invention are selected from losartan, irbesartan, telmisartanand candesartan, which have shown to bind to and activate ppar gamma(Drug Development Research 67:579-581, 2006). Treatment with sartans hasbeen suggested to improve multiple sclerosis. The sartanes arepredominantly used in the treatment of hypertension, diabeticnephropathy (kidney damage due to diabetes) and chronic kidney diseaseas well as congestive heart failure and are also preferably employed forthese diseases and conditions when combined with Nrf2 activatorsaccording to the present invention.

In a further preferred embodiment of the present inventions, ppar gammaagonists are selected from nonsteroidal anti-inflammatory drugs (NSAIDs)having ppar gamma activating properties, preferably indomethacin,flufenamic acid, fenoprofen and ibuprofen (The Journal of BiologicalChemistry, vol. 272, no. 6, issue 7, pp. 3406-3410, 1997). NSAIDs areincluded in the definition of PPAR gamma agonists for the purposes ofthe present invention as they may bind directly to the PPAR or act as aphysiological PPAR gamma agonist. In one embodiment, NSAIDs other thanaspirin are preferred.

The group of NSAIDs comprises the following compounds: Salicylates, suchas aspirin (acetylsalicylic acid), diflunisal, salsalate, propionic acidderivatives such as ibuprofen, dexibuprofen, naproxen, fenoprofen,ketoprofen, dexketoprofen, flurbiprofen, oxaprozin, loxoprofen, aceticacid derivatives such asindomethacin, sulindac, etodolac, ketorolac,diclofenac, nabumetone, enolic acid (oxicam) derivatives such aspiroxicam, meloxicam, tenoxicam, droxicam, lornoxicam, isoxicam, fenamicacid derivatives (fenamates) such as mefenamic acid, meclofenamic acid,flufenamic acid, tolfenamic acid, selective cox-2 inhibitors (coxibs)such as celecoxib, rofecoxib, valdecoxib, parecoxib, lumiracoxib,etoricoxib, firocoxib, sulphonanilides such as nimesulide and otherssuch as licofelone, lysine clonixinate.

Nrf2-activating compounds can be classified based on their chemicalstructures: Diphenols, Michael reaction acceptors, isothiocyanates,thiocarbamates, trivalent arsenicals, 1,2-dithiole-3-thiones,hydroperoxides, vicinal dimercaptans, heavy metals, and polyenes.Moreover, Nrf2 activators (i) all are chemically reactive; (ii) nearlyall are electrophiles; (iii) most are substrates for glutathionetransferases; and (iv) all can modify sulfhydryl groups by alkylation,oxidation, or reduction (PNAS Feb. 17, 2004 vol. 101 no. 7 2040-2045,Mol. Cell. Biol. 2009, 29(2):493). The activity of the compounds can beidentified by known methods.

Preferred Nrf2 activators are compounds without significant PPAR gammaagonistic effect. These are preferably compounds, which may or may notbind covalently to the PPA receptor, but are not able to change theconformation of the PPAR and preferably the PPA gamma receptor to anextent that this would result in an activation of the PPA receptor.According to the present invention these preferred Nrf2 activators aresmall and of low molecular weight. These compounds are preferablylacking the structural elements to bind to the PPA receptornon-covalently with the result of a change of conformation andactivation of the PPA receptor. In a preferred embodiment, the Nrf2activators may be able to bind covalently to the PPA receptor, e.g. viaa Michael reaction with a thiol group of the PPA receptor, withoutresulting in a conformation change of the PPA receptor. Due to theirlimited size however, these preferred Nrf2 activators may not preventPPAR agonists, and in particular PPAR gamma agonists, especiallyglitazones such as pioglitazone or rosiglitazone from bindingnon-covalently to the PPA receptor with the result of a conformationchange.

In a very preferred example, the covalent binding of a Nrf2 activatorsuch as monomethyl hydrogen fumarate or dimethyl fumarate and thenon-covalent binding of a PPAR gamma agonist such as a glitazone, likepioglitazone or rosiglitazone leads to synergistic and strongly improvedtherapeutic results.

In one embodiment, the preferred are Nrf2 activators selected fromorganic compounds having not more than one or two 5- or 6-memberedcarbocyclic rings or 5- or 6-membered heterocyclic rings having 1, 2 or3 N—, O or S-atoms as ring atoms which may be fused to each other orpreferably no or only one carbocyclic or heterocyclic ring and/or lessthan 35, preferably less than 30, more preferably less than 25 and mostpreferably less than 20 or even less than 15 or less than 10 carbonatoms and/or have a molecular weight of less than 400, preferably lessthan 300 and most preferably less than 200 g/mol or less than 170 g/moland are selected from the chemical classes of Michael reactionacceptors, phenols, diphenols, chalcones, isothiocyanates,thiocarbamates, quinones, naphtoquinones and 1,2 dithiole-3-thiones,wherein one or more, preferably up to seven H-atoms may be substitutedby linear or branched alkyl and perfluoroalkyl, such as methyl, ethyl,trifluoromethyl, halogen such as Br, Cl, F or I, hydroxy, alkoxy andperfluoroalkoxy, such as methoxy, ethoxy, trifluoromethoxy, cyano andnitro.

In cases where compounds of the chemical class of quinones are employedas Nrf2 activator, the respective hydroquinones can be usedalternatively. However the respective oxidized form, i.e. the respectivequinone, is preferred. The Nrf2 activity can be determined according toe.g. JALA 2008; 13: 243-248. Bardoxolone methyl and derivatives aredescribed in U.S. Pat. No. 8,129,429, US7435755 and US2009/0060873.Amorphous Bardoxolone methyl and suitable formulations are disclosed inWO2010/093944.

Very preferred Nrf2 activators are capable of provoking or inducing astimulated and/or increased nuclear translocation of Nrf2 protein andare:

a) selected from the group of Michael reaction acceptors, phenols,diphenols, chalcones, isothiocyanates, thiocarbamates, quinones,naphtoquinones and 1,2 dithiole-3-thiones; and

b) contain less than 35 carbon atoms; and/or

c) have a molecular weight of less than 600 g/mol; and/or

d) contain no or not more than one or two fused or monocyclic 5- or6-membered carbocyclic or heterocyclic rings, having 1, 2 or 3 ringatoms selected from N, O or S.

In these preferred Nrf2 activators, one or more, preferably up to sevenH-atoms may be substituted preferably by linear or branched alkyl andperfluoroalkyl, such as methyl, ethyl, trifluoromethyl, halogen such asBr, Cl, F or I, hydroxy, alkoxy and perfluoroalkoxy, such as methoxy,ethoxy, trifluoromethoxy, cyano and nitro.

More preferred embodiments of these Nrf2 activators contain no ringsystem or only one or two rings, which may be carbocyclic and/orheterocyclic rings. Even more preferred Nrf2 activators contain lessthan 30, more preferably less than 25 and most preferably less than 20or even less than 15 or less than 10 carbon atoms and/or have amolecular weight of less than 400 g/mol and more preferably less than300 g/mol and most preferably less than 200 g/mol or less than 170g/mol. Further preferred Nrf2 activators bind covalently to Keaplprotein, preferably via an S-atom of the proteins amino acids.

Preferred Michael reaction acceptors are ketones, aldehydes, carboxylicacid esters and carboxylic acid amides all of which being alpha, betaunsaturated.

More preferred Nrf2 activators are the compounds A to Z given below,including their tautomers and stereoisomers:

Wherein the individual radicals have the meaning given below:R¹ H, OH, Hal, CN, A, perfluoroalkyl, perfluoroalkoxyR² H, OH, A, alkoxy, aminoR³ H, alkylR⁴ H, OH, alkyl, alkoxyR⁵ H, OH, A, alkoxyR⁶ H, A, alkoxy, aryl, hetR⁷ H, OH, A, alkoxy

R⁸ A X O, NH, S R⁹ Het

m 1, 2n 1, 2, 3

Hal is F, Cl, Br or I, preferably F or Cl.

A is preferably alkyl which denotes a straight or branched carbon chainhaving 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, or 12 carbon atoms. Alkylpreferably denotes methyl, ethyl, propyl, isopropyl, butyl, isobutyl,sec-butyl or tert-butyl, furthermore also pentyl, 1-, 2- or3-methylbutyl, 1,1-, 1,2- or 2,2-dimethylpropyl, 1-ethylpropyl, hexyl,1-, 2-, 3- or 4-methylpentyl, 1,1-, 1,2-, 1,3-, 2,2-, 2,3- or3,3-dimethylbutyl, 1- or 2-ethylbutyl, 1-ethyl-1-methylpropyl,1-ethyl-2-methylpropyl, 1,1,2- or 1,2,2-trimethylpropyl. Alternatively,A denotes cycloalkyl having 3, 4, 5, 6 or 7 carbon atoms or branched orlinear alkyl having 2 to 12 C-atoms, wherein one or more, preferably 1to 7 H-atoms may be replaced by Hal, alkyl, alkoxy, cycloalkyl, phenyl,p-, m- o-hydroxyphenyl, p-, m- o-alkoxyphenyl, N(R³)₂, OH, CO₂H, CF₃and/or wherein one or more, preferably 1 to 7 non-adjacent CH₂-groupsmay be replaced by —O—, —S—, —SO—, —NR³—, —CO—, —CO₂—, —CH═CH—S— and/or—CH═CH—. Cycloalkyl preferably denotes cyclopropyl, cyclobutyl,cyclopentyl, cyclohexyl or cycloheptyl.

Alkoxy is preferably a group O-alkyl, wherein alkyl is defined as above.Preferably, alkoxy denotes a group —O—(CH₂)_(n)—CH₃, wherein n is 0, 1,2, 3 or 4, more preferably methoxy or ethoxy.

Perfluoroalkyl preferably denotes a straight or branched alkyl chainhaving 1 to 8 carbon atoms, preferably 1 to 6 carbon atoms, and whereinall hydrogen atoms are replaced by F atoms, preferably, for example,trifluoromethyl or pentafluoroethyl.

Perfluoroalkoxy is preferably a group O-perfluoroalkyl, whereinperfluoroalkyl is defined as above. Perfluoroalkoxy preferably denotesOCF₃.

Amino denotes preferably the group —NR′R″ where each R′, R″ isindependently hydrogen or alkyl. The group —NR′R″ can also form a cyclicgroup selected from piperidinyl, piperazinyl, pyrrolyl or morpholinyl,wherein one, two or three H atoms may be substituted by alkyl, such asmethyl. In one embodiment, amino denotes dialkylamino, wherein alkyl hasthe meaning given above and is preferably dimethylamino.

Aryl preferably denotes a monocyclic or bicyclic, aromatic carbocyclicring having 6 to 14 carbon atoms, which is unsubstituted ormonosubstituted, disubstituted or trisubstituted by F, Cl, Br, CF₃,OCF₃, NO₂, CN, alkyl, alkoxy, OH, amino, CO-amino, NHCO-alkyl, CO-alkyl,CO-alkoxy, SO₂-alkyl, SO₂-amino. Most preferably, aryl denotesunsubstituted or monosubstituted phenyl.

Het preferably denotes, notwithstanding further substitutions, a 6 to 14membered monocyclic or bicyclic saturated, unsaturated or aromaticheterocyclic ring system containing 1 or 2 heteroatoms selected from N,O and S, which is unsubstituted or monosubstituted, disubstituted ortrisubstituted by F, Cl, Br, CF₃, OCF₃, NO₂, CN, alkyl, alkoxy, OH,amino, CO-amino, NHCO-alkyl, CO-alkyl, CO-alkoxy, SO₂-alkyl, SO₂-amino.More preferably, Het is 2- or 3-furyl, 2- or 3-thienyl, 1-, 2- or3-pyrrolyl, 1-, 2-, 4- or 5-imidazolyl, 1-, 3-, 4- or 5-pyrazolyl, 2-,4- or 5-oxazolyl, 3-, 4- or 5-isoxazolyl, 2-, 4- or 5-thiazolyl, 3-, 4-or 5-isothiazolyl, 2-, 3- or 4-pyridyl, 2-, 4-, 5- or 6-pyrimidinyl,furthermore preferably 1,2,3-triazol-1-, -4- or -5-yl, 1,2,4-triazol-1-,-3- or -5-yl, 1- or 5-tetrazolyl, 1,2,3-oxadiazol-4- or -5-yl,1,2,4-oxadiazol-3- or -5-yl, 1,3,4-thiadiazol-2- or -5-yl,1,2,4-thiadiazol-3- or -5-yl, 1,2,3-thiadiazol-4- or -5-yl, 3- or4-pyridazinyl, pyrazinyl, 1-, 2-, 3-, 4-, 5-, 6- or 7-indolyl,indazolyl, 4- or 5-isoindolyl, 1-, 2-, 4- or 5-benzimidazolyl, 1-, 3-,4-, 5-, 6- or 7-benzopyrazolyl, 2-, 4-, 5-, 6- or 7-benzoxazolyl, 3-,4-, 5-, 6- or 7-benzisoxazolyl, 2-, 4-, 5-, 6- or 7-benzothiazolyl, 2-,4-, 5-, 6- or 7-benzisothiazolyl, 4-, 5-, 6- or7-benz-2,1,3-oxa-diazolyl, 2-, 3-, 4-, 5-, 6-, 7- or 8-quinolyl, 1-, 3-,4-, 5-, 6-, 7- or 8-isoquinolyl, 3-, 4-, 5-, 6-, 7- or 8-cinnolinyl, 2-,4-, 5-, 6-, 7- or 8-quinazolinyl, 5- or 6-quinoxalinyl, 2-, 3-, 5-, 6-,7- or 8-2H-benzo-1,4-oxazinyl, furthermore preferably1,3-benzodioxol-5-yl, 1,4-benzodioxane-6-yl, 2,1,3-benzothiadiazol-4- or-5-yl or 2,1,3-benzoxadiazol-5-yl. The heterocyclic radicals may also bepartially or fully hydrogenated. Het can thus also denote, for example,2,3-dihydro-2-, -3-, -4- or -5-furyl, 2,5-dihydro-2-, -3-, -4- or-5-furyl, tetrahydro-2- or -3-furyl, 1,3-dioxolan-4-yl, tetrahydro-2- or-3-thienyl, 2,3-dihydro-1-, -2-, -3-, -4- or -5-pyrrolyl,2,5-dihydro-1-, -2-, -3-, -4- or -5-pyrrolyl, 1-, 2- or 3-pyrrolidinyl,tetrahydro-1-, -2- or -4-imidazolyl, 2,3-dihydro-1-, -2-, -3-, -4- or-5-pyrazolyl, tetrahydro-1-, -3- or -4-pyrazolyl, 1,4-dihydro-1-, -2-,-3- or -4-pyridyl, 1,2,3,4-tetrahydro-1-, -2-, -3-, -4-, -5- or-6-pyridyl, 1-, 2-, 3- or 4-piperidinyl, 2-, 3- or 4-morpholinyl,tetrahydro-2-, -3- or -4-pyranyl, 1,4-dioxaneyl, 1,3-dioxane-2-, -4- or-5-yl, hexahydro-1-, -3- or -4-pyridazinyl, hexahydro-1-, -2-, -4- or-5-pyrimidinyl, 1-, 2- or 3-piperazinyl, 1,2,3,4-tetrahydro-1-, -2-,-3-, -4-, -5-, -6-, -7- or -8-quinolyl, 1,2,3,4-tetrahydro-1-, -2-, -3-,-4-, -5-, -6-, -7- or -8-isoquinolyl, 2-, 3-, 5-, 6-, 7- or8-3,4-dihydro-2H-benzo-1,4-oxazinyl, furthermore preferably2,3-methylenedioxyphenyl, 3,4-methylenedioxyphenyl,2,3-ethylenedioxyphenyl, 3,4-ethylenedioxyphenyl,3,4-(difluoromethylenedioxy)phenyl, 2,3-dihydrobenzofuran-5- or -6-yl,2,3-(2-oxomethylenedioxy)phenyl or also3,4-dihydro-2H-1,5-benzodioxepin-6- or -7-yl, furthermore preferably2,3-dihydrobenzofuranyl or 2,3-dihydro-2-oxofuranyl. Very preferably,heteroaryl is unsubstituted or monosubstituted 2-pyridyl, pyrimidyl orimidazolyl.

R¹ is preferably H, OH, F, methyl, methoxy, trifluoromethoxy.

R² is preferably H, OH, alkoxy, such as methoxy, OCH₂CH₂-phenyl.

R³ is preferably H or alkyl, preferably H, methyl or tert-butyl.

R⁴ is preferably H, OH, alkoxy, such as methoxy.

R⁵ is preferably H or A.

R⁶ is preferably H or Het.

R⁷ is preferably (CH₂)_(m)COR², (CH₂)_(m)COR², O(CH₂)_(m)COR² orO(CH₂)_(m)COR².

R⁸ is preferably allyl or a group selected from (C(R³)₂)_(q)S-alkyl or(C(R³)₂)_(q)SO-alkyl, wherein q is 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11 or12.

Preferred Nrf2 activators are selected from: Chalcone derivatives asdisclosed in J. Med. Chem., 2011, 54 (12), pp 4147-4159, such as2-trifluoromethyl-2′-methoxychalcone, auranofin, ebselen,1,2-naphthoquinone, cynnamic aldehyde, caffeic acid and its esters,curcumin, reservatrol, artesunate, tert-butylhydroquinone, and -quinone,(tBHQ, tBQ), vitamins K1, K2 and K3, preferably menadione, fumaric acidesters, i.e. fumaric acid mono- and/or diester which is preferablyselected from the group of monoalkyl hydrogen fumarate and dialkylfumarate, such as monomethyl hydrogen fumarate, dimethyl fumarate,monoethyl hydrogen fumarate, and diethyl fumarate, 2-cyclopentenones,ethacrynic acid and its alkyl esters, bardoxolone methyl (methyl2-cyano-3,12-dioxooleana-1,9(11)dien-28-oate) (CDDO-Me, RTA 402), ethyl2-cyano-3,12-dioxooleana-1,9(11)dien-28-oate,2-cyano-3,12-dioxooleana-1,9(11)dien-28-oic acid (CDDO), 1[2-Cyano-3,12-dioxooleana-1,9(11)-dien-28-oyl]imidazole (CDDO-Im),(2-cyano-N-methyl-3,12-dioxooleana-1,9(11)-dien-28 amide (CDDO-methylamide, CDDO-MA), isothiocyanate such as sulforaphane,1,2-dithiole-3-thione such as oltipraz,3,5-di-tert-butyl-4-hydroxytoluene, 3-hydroxycoumarin, 4-hydroxynonenal,4-oxononenal, malondialdehyde, (E)-2-hexenal, capsaicin, allicin,allylisothiocyanate, 6-methylthiohexyl isothiocyanate,7-methylthioheptyl isothiocyanate, sulforaphane, 8-methylthiooctylisothiocyanate, corticosteroids, such as dexamethasone, 8-isoprostaglandin A2, alkyl pyruvate, such as methyl and ethyl pyruvate,diethyl or dimethyl oxaloproprionate, 2-acetamidoacrylate, methyl orethyl-2-acetamidoacrylate, hypoestoxide, parthenolide, eriodictyol,4-Hydroxy-2-nonenal, 4-oxo-2nonenal, geranial, zerumbone, aurone,isoliquiritigenin, xanthohumol, [10]-Shogaol, eugenol,1′-acetoxychavicol acetate, allyl isothiocyanate, benzyl isothiocyanate,phenethyl isothiocyanate, 4-(Methylthio)-3-butenyl isothiocyanate and6-Methylsulfinylhexyl isothiocyanate, ferulic acid and its esters, suchas ferulic acid ethyl ester, and ferulic acid methyl ester, sofalcone,4-methyl daphnetin, imperatorin, auraptene, poncimarin,bis[2-hydroxybenzylidene]acetones, alicylcurcuminoid, 4-bromo flavone,β-naphthoflavone, sappanone A, aurones and its corresponding indolederivatives such as benzylidene-indolin-2-ones, perillaldehyde,quercetin, fisetin, koparin, genistein, tanshinone HA, BHA, BHT,PMX-290, AL-1, avicin D, gedunin, fisetin, andrographolide, tricyclicbis(cyano enone) TBE-31[(±)-(4bS,8aR,10aS)-10a-ethynyl-4-b,8,8-trimethyl-3,7-dioxo-3,4-b,7,8,8a,9,10,10a-octahydrophenanthrene-2,6-dicarbonitrile],MCE-1, MCE5, TP-225, ADT as referred to in in Medicinal ResearchReviews, 32, No. 4, 687-726, 2012, and the respective quinone orhydroquinone forms of the aforementioned quinone and hydroquinonederivatives and stereoisomers, tautomers or pharmacologically activederivatives of the aforementioned agents.

Very preferred Nrf2 activators are selected from: carnosic acid,2-naphthoquinone, cynnamic aldehyde, caffeic acid and its esters,curcumin, reservatrol, artesunate, tert-butylhydroquinone, vitamins K1,K2 and K3, fumaric acid esters, i.e. fumaric acid mono- and/or diesterwhich is preferably selected from the group of monoalkyl hydrogenfumarate and dialkyl fumarate, such as monomethyl hydrogen fumarate,dimethyl fumarate, monoethyl hydrogen fumarate, and diethyl fumarate,isothiocyanate such as sulforaphane, 1,2-dithiole-3-thione such asoltipraz, 3,5-di-tert-butyl-4-hydroxytoluene, 3-hydroxycoumarin,4-hydroxynonenal, 4-oxononenal, malondialdehyde, (E)-2-hexenal,capsaicin, allicin, allylisothiocyanate, 6-methylthiohexylisothiocyanate, 7-methylthioheptyl isothiocyanate, sulforaphane,8-methylthiooctyl isothiocyanate, 8-iso prostaglandin A2, alkylpyruvate, such as methyl and ethyl pyruvate, diethyl or dimethyloxaloproprionate, 2-acetamidoacrylate, methyl orethyl-2-acetamidoacrylate, hypoestoxide, parthenolide, eriodictyol,4-Hydroxy-2-nonenal, 4-oxo-2nonenal, geranial, zerumbone, aurone,isoliquiritigenin, xanthohumol, [10]-Shogaol, eugenol,1′-acetoxychavicol acetate, allyl isothiocyanate, benzyl isothiocyanate,phenethyl isothiocyanate, 4-(Methylthio)-3-butenyl isothiocyanate and6-Methylsulfinylhexyl isothiocyanate and the respective quinone orhydroquinone forms of the aforementioned quinone and hydroquinonederivatives, and stereoisomers, tautomers or pharmacologically activederivatives of the aforementioned agents. Very preferred Nrf2 activatorsare Michael reaction acceptors such as dimethylfumarate, monomethylhydrogen fumarate isothiocyanates and 1,2-dithiole-3-thiones. In anotherembodiment, very preferred Nrf2 activators are selected from monomethylhydrogen fumarate, dimethyl fumarate, oltipraz, 1,2-naphthoquinone,tert-butylhydroquinone, methyl or ethyl pyruvate,3,5-di-tert-butyl-4-hydroxytoluene, diethyl and dimethyloxaloproprionate, hypoestoxide, parthenolide, eriodictyol,4-Hydroxy-2-nonenal, 4-oxo-2nonenal, geranial, zerumbone, aurone,isoliquiritigenin, xanthohumol, [10]-Shogaol, eugenol,1′-acetoxychavicol acetate, allyl isothiocyanate, benzyl isothiocyanate,phenethyl isothiocyanate, 4-(Methylthio)-3-butenyl isothiocyanate and6-Methylsulfinylhexyl isothiocyanate. It is particularly advantageousthat the use of the PPAR gamma agonist and the Nrf2 activator accordingto the present invention may allow for the maximum dosage of each agentwhen used in mono-therapy, which result in maximal therapeutic effect.No or only very limited increase in adverse side effects known for theindividual PPAR gamma agonist or the Nrf2 activator can be observed. Itmay also be advantageous to reduce the dose of one or both of the agentsemployed in the combination treatment of the present invention. Thus,side effects that may be observed in mono-therapy with the agents may beavoided or reduced. Throughout the specification, the term“pharmacologically active derivatives” denotes preferably salts, amidesand esters, such as alkylesters including methyl and ethyl esters, ofpharmacologically active acids and alkanoic acid esters and ethers ofpharmocologically active alcohols, such as acetic acid esters and methylethers as well as alkanoic acid amides of pharmocologically activeamines, such as the respective acetic acid amide.

The combination treatment of the present invention can be furthercombined with treatments and medicaments that are generally used in thevarious indications as a standard treatment. In the treatment ofmultiple sclerosis for example, the combination treatment of the presentinvention can be further combined with interferon, such as interferonbeta 1b or interferon beta 1a (Rebif, Avonex) or glatiramer acetate(Copaxone), a sphingosine 1-phosphate receptor modulator, such asFingolimod (Gilenya) and/or methotrexate. The combination treatment ofthe present invention can be further combined with RXR specific ligands,such as 9-cis-retinoic acid (RA) in order to obtain even furtherimproved results, particularly in the treatment of psoriasis.

The combination therapy according to the present invention may beadministered as a simultaneous or sequential regimen, also referred toas co-administration. When administered sequentially, the combinationmay be administered in two or more administrations. It is also possibleto combine any PPAR gamma agonist with an Nrf2 activator in a unitarydosage form for simultaneous or sequential administration to a patient.

In general, for compositions containing fumaric acid esters, anadministration twice daily (BID) or thrice daily (TID) is preferred. Thedosages of the individual agents are adjusted accordingly.

Co-administration of a PPAR gamma agonist with an Nrf2 activatoraccording to the invention generally and preferably refers tosimultaneous or sequential administration of a PPAR gamma agonist and anNrf2 activator, such that therapeutically effective amounts of the PPARgamma agonist and the Nrf2 activator are both present at the same timein the body of the patient.

Co-administration includes simultaneous administration andadministration of the an agent according to the invention before orafter administration of the other agent, for example, administration ofboth agents according to the invention within seconds, minutes, orhours. In one embodiment, the first agent is administered, followed,after a period of hours, e.g., 0.25-12 hours, preferably 0.5 to 3 hoursmost preferably 1 to 2 hours), by administration of the second agent.

The combination therapy and co-administration according to the inventionfrequently provides “synergy” and “synergistic effect”, i.e. thetherapeutic effect achieved when the PPAR gamma agonist and the Nrf2activator are used together is more than additive, i.e. greater than thesum of the effects that result from using each agent alone.

An appropriate dose of a PPAR agonist and an Nrf2 activator orpharmaceutical composition comprising a PPAR agonist and an Nrf2activator for use in the present invention, may be determined accordingto any one of several well-established protocols. For example, animalstudies such as studies using mice, rats, dogs, and/or monkeys may beused to determine an appropriate dose of a pharmaceutical compound.Results from animal studies may be extrapolated to determine doses foruse in other species, such as for example, humans.

In general, a preferred PPAR gamma agonist is administered incombination with a preferred Nrf2 activator according to the invention,preferably orally, in daily dosages of 0.01 mg to 50 mg per kg bodyweight, dependent on the activity and safety of the respective PPARgamma agonist. If not indicated otherwise, the dosages given above andbelow reflect the amount of free base of the PPAR gamma agonist, even ifused in form of the maleate or another acid addition salt.

Preferred nrf 2 activators are bardoxolone methyl and dialkyl fumaratesuch as dimethyl fumarate and diethyl fumarate.

The dialkyl fumarates to be used according to the invention are preparedby processes known in the art (see, for example, EP 0 312 697).

Preferably, the active ingredients, i.e. the agents, are used forpreparing oral preparations in the form of tablets, micro-tablets,pellets or granulates, optionally in capsules or sachets. Preparationsin the form of micro-tablets or pellets, optionally filled in capsulesor sachets are preferred and are also a subject matter of the invention.According to a preferred embodiment, the size or the mean diameter,respectively, of the pellets or micro-tablets is in the range from 300to 2,000 μm, especially in the range of 500 or 1,000 μm.

The oral preparations may be provided with an enteric coating. Capsulesmay be soft or hard gelatine capsules.

The dialkyl fumarates used according to the invention may be used aloneor as a mixture of several compounds, optionally in combination with thecustomary carriers and excipients. The amounts to be used are selectedin such a manner that the preparations, such as tablets, obtainedcontain the active ingredient in an amount corresponding to 10 to 300 mgof fumaric acid per dosage unit.

Preferred preparations according to the invention contain a total amountof 10 to 300 mg of dimethyl fumarate and/or diethyl fumarate.

Fixed-dose combinations of a PPAR agonist and preferably a PPAR gammaagonist with an Nrf2 activator are preferred. Fixed-dose combinations ofrosiglitazone with dimethyl fumarate and rosiglitazone with bardoxolonemethyl are particularly preferred. Fixed-dose combinations ofpioglitazone with dimethyl fumarate and rosiglitazone with bardoxolonemethyl are particularly preferred.

In particular, rosiglitazone is preferably administered according to theinvention in form of its maleate in daily dosages of 0.01 to 0.2 mg perkg body weight, more preferably in daily dosages of 0.02 to 0.16 mg perkg body weight and most preferably in daily dosages of 0.025 mg to 0.14mg per kg body weight, such as in daily dosages of 0.03 mg, 0.06 mg or0.12 mg per kg body weight. Daily oral dosages of 2 mg, 4 mg and 8 mgrosiglitazone per patient are particularly preferred.

In particular, pioglitazone is preferably administered according to theinvention in form of its hydrochloride in daily dosages of 0.05 to 1 mgper kg body weight, more preferably in daily dosages of 0.1 to 0.8 mgper kg body weight and most preferably in daily dosages of 0.15 mg to0.7 mg per kg body weight, such as in daily dosages of about 0.2 mg,about 0.4 mg or about 0.6 mg per kg body weight. Daily oral dosages ofabout 15 mg, about 30 mg and about 45 mg pioglitazone per patient areparticularly preferred.

In particular, ciglitazone or troglitazone are preferably administeredaccording to the invention in daily dosages of 1 to 20 mg per kg bodyweight, more preferably in daily dosages of 2 to 15 mg per kg bodyweight and most preferably in daily dosages of 3 mg to 10 mg per kg bodyweight. Oral dosages are particularly preferred.

In general, a preferred Nrf2 activator is administered in combinationwith a preferred PPAR gamma agonist, preferably orally, in daily dosagesof 0.1 mg to 20 mg per kg body weight, dependent on the activity andsafety of the respective Nrf2 activator.

In particular, bardoxolone methyl is preferably administered accordingto the invention in daily dosages of 0.1 to 3 mg per kg body weight,more preferably in daily dosages of 0.2 to 2.5 mg per kg body weight andmost preferably in daily dosages of 0.3 mg to 2.2 mg per kg body weight,such as in daily dosages of about 0.35 mg, about 1.1 mg or about 2 mgper kg body weight. Daily oral dosages of about 25 mg, about 75 mg andabout 150 mg bardoxolone methyl per patient are particularly preferred.

In particular, dimethyl fumarate is preferably administered according tothe invention in daily dosages of 1 to 20 mg per kg body weight, morepreferably in daily dosages of 2 to 15 mg per kg body weight and mostpreferably in daily dosages of 3 mg to 12 mg per kg body weight, such asin daily dosages of about 3.4 mg, about 7 mg or about 10 mg per kg bodyweight. Daily oral dosages of about 240 mg, about 480 mg and about 720mg dimethyl fumarate per patient are particularly preferred.

The ratio between the dosages of the PPAR gamma agonist and the Nrf2activator used in the combinations according to the present invention,depends on the activity of the particular PPAR gamma agonist and Nrf2activator selected.

Daily oral dosages of 2 mg, 4 mg and 8 mg rosiglitazone per patient areparticularly preferred.

Daily oral dosages of about 20 mg, about 25 mg, about 75 mg and about150 mg bardoxolone methyl per patient are particularly preferred. Incase bardoxolone methyl is employed in amorphous form, daily dosages ofabout 20 mg per patient are most preferred.

Daily oral dosages of about 120 mg, about 240 mg, about 360 mg, about480 mg, about 600 mg and about 720 mg dimethyl fumarate per patient areparticularly preferred.

If the Nrf2 activator is dimethyl fumarate, once or twice daily dosingis preferred.

Preferred dosage forms and in particular oral dosage forms such astablets or capsules may contain:

For daily administration, dosage forms such as tablets or capsules maycontain preferably about 2 mg rosiglitazone and about 25 mg bardoxolonemethyl or about 2 mg rosiglitazone and about 75 mg bardoxolone methyl orabout 2 mg rosiglitazone and about 150 mg bardoxolone methyl or about 4mg rosiglitazone and about 25 mg bardoxolone methyl or about 4 mgrosiglitazone and about 75 mg bardoxolone methyl or about 4 mgrosiglitazone and about 150 mg bardoxolone methyl or about 8 mgrosiglitazone and about 25 mg bardoxolone methyl or about 8 mgrosiglitazone and about 75 mg bardoxolone methyl or about 8 mgrosiglitazone and about 150 mg bardoxolone methyl. Most preferably, adosage form may contain about 8 mg rosiglitazone and about 150 mgbardoxolone methyl.

For administration three times daily, preferred dosage forms such astablets or capsules may contain about 0.7 mg, preferably about 0.67 mg,rosiglitazone and 240 mg dimethyl fumarate or about 1.3 mg, preferablyabout 1.33 mg, rosiglitazone and about 240 mg dimethyl fumarate or about2.7 mg preferably about 2.67 mg, rosiglitazone and about 240 mg dimethylfumarate or about 0.7 mg, preferably about 0.67 mg, rosiglitazone and120 mg dimethyl fumarate or about 1.3 mg, preferably about 1.33 mg,rosiglitazone and about 120 mg dimethyl fumarate or about 2.7 mgpreferably about 2.67 mg, rosiglitazone and about 120 mg dimethylfumarate. Most preferably, a dosage form may contain about 2.7 mgpreferably about 2.67 mg, rosiglitazone and about 240 mg dimethylfumarate.

For administration two times daily, preferred dosage forms such astablets or capsules may contain about 1 mg rosiglitazone and about 240mg dimethyl fumarate or about 2 mg rosiglitazone and about 240 mgdimethyl fumarate or about 4 mg rosiglitazone and about 240 mg dimethylfumarate.

For daily administration, dosage forms such as tablets or capsules maycontain preferably about 15 mg pioglitazone and about 25 mg bardoxolonemethyl or about 15 mg pioglitazone and about 75 mg bardoxolone methyl orabout 15 mg pioglitazone and about 150 mg bardoxolone methyl or about 30mg pioglitazone and about 25 mg bardoxolone methyl or about 30 mgpioglitazone and about 75 mg bardoxolone methyl or about 30 mgpioglitazone and about 150 mg bardoxolone methyl or about 45 mgpioglitazone and about 25 mg bardoxolone methyl or about 45 mgpioglitazone and about 75 mg bardoxolone methyl or about 45 mgpioglitazone and about 150 mg bardoxolone methyl. Most preferably, adosage form may contain about 45 mg pioglitazone and about 150 mgbardoxolone methyl.

For administration three times daily, preferred dosage forms such astablets or capsules may contain about 5 mg pioglitazone and 240 mgdimethyl fumarate or about 10 mg pioglitazone and about 240 mg dimethylfumarate or about 15 mg pioglitazone and about 240 mg dimethyl fumarateor about 5 mg pioglitazone and 120 mg dimethyl fumarate or about 10 mgpioglitazone and about 120 mg dimethyl fumarate or about 15 mgpioglitazone and about 120 mg dimethyl fumarate, Most preferably, adosage form may contain about 15 mg pioglitazone and about 240 mgdimethyl fumarate.

For administration two times daily, preferred dosage forms such astablets or capsules may contain about 7.5 mg pioglitazone and about 240mg dimethyl fumarate or about 15 mg pioglitazone and about 240 mgdimethyl fumarate or about 22.5 mg pioglitazone and about 240 mgdimethyl fumarate.

In particular, atorvastatin is preferably administered according to theinvention in form of its calcium salt in daily oral dosages of about 10,about 20, about 40 or about 80 mg per patient. Preferably, atorvastatinis combined in the above dosages with dimethylfumarate in dosages ofabout 120, about 240 or about 360, about 480 or about 720 mg per day.Most preferred are combinations containing about 20 mg or about 40 mg ofatorvastatin in form of its calcium salt, and about 240 mg dimethylfumarate.

In a further embodiment, atorvastatin is combined in the above dosageswith bardoxolone methyl in its amorphous form in dosages of about 20 mgper day. Most preferred are combinations containing about 40 mg or about80 mg of atorvastatin in form of its calcium salt, and about 20 mgbardoxolone methyl in its amorphous form.

In particular, losartan is preferably administered according to theinvention in daily oral dosages of about 25, about 50, about 75 or about100 mg per patient. Preferably, losartan is combined in the abovedosages with dimethylfumarate in dosages of about 120, about 240 orabout 360, about 480 or about 720 mg per day. Most preferred arecombinations containing about 25 mg or about 50 mg of losartan, andabout 240 mg dimethyl fumarate. The combination is preferablyadministered twice daily. The combination treatments of sartanes andpreferably losartan, irbesartan, telmisartan and candesartan with Nrf2activators such as dimethyl fumarate and bardoxolone methyl areparticularly effective for the treatment of diabetic nephropathy (kidneydamage due to diabetes) and chronic kidney disease, but also for thetreatment of multiple sclerosis.

In a further example, losartan is combined in the above dosages withbardoxolone methyl in its amorphous form in dosages of about 20 mg perday. Most preferred are combinations containing about 25 mg or about 50mg of losartan, and about 20 mg bardoxolone methyl in its amorphousform. The combination is preferably administered once daily.

In particular, ibuprofen is preferably administered according to theinvention in daily dosages that are applicable to the monotherapy withibuprofen, such as about 600 mg, about 800 mg or about 1200 mg or about2400 mg per patient. Most preferred are combinations containing about600 mg of ibuprofen and about 240 mg dimethyl fumarate. The combinationis preferably administered twice daily.

In a further example, ibuprofen is combined in the above dosages withbardoxolone methyl in its amorphous form in dosages of about 20 mg perday. Most preferred are combinations containing about 800 mg ofibuprofen, and about 20 mg bardoxolone methyl in its amorphous form. Thecombination is preferably administered once daily.

Preferred ratios between rosiglitazone and dimethyl fumarate areselected from 1/20 to 1/400 (w/w, rosiglitazone/dimethyl fumarate),preferably from 1/25 to 380, more preferably from 1/28 to 1/360. Mostpreferably the ratios are about 1/30, about 1/45, such as about 1/44.4,about 1/60, about 1/90, such as about 1/88.9 or about 1/92.3, about1/120, about 1/180, such as 1/171.4 or 1/184.6, about 1/240, about1/340, such as about 1/342.9.

Preferred ratios between pioglitazone and dimethyl fumarate are selectedfrom 1/3 to 1/60 (w/w, pioglitazone/dimethyl fumarate), preferably from1/4 to 1/55, more preferably from 1/5 to 1/52. Most preferably theratios are about 1/5.3, about 1/8, about 1/10, such as 1/10.7, about1/12, about 1/16, about 1/24, about 1/32, about 1 to 48.

In general, ratios between rosiglitazone and bardoxolone methyl areselected from 1/1 to 1/100 (w/w, rosiglitazone/bardoxolone methyl),preferably from 1/1.5 to 1/80, more preferably from 1/2 to 1/75. Mostpreferably the ratios are about 1/2.5, such as about 1/3.1 or about 1/5,such as 1/6.3, about 1/10, such as about 1/9.4 or about 1/12.5, about1/20, such as 1/18.8, about 1/40, such as about 1/37.5, about 1/70, suchas about 1/75.

In general, ratios between pioglitazone and bardoxolone methyl areselected from 1/0.1 to 1/20 (w/w, pioglitazone/bardoxolone methyl),preferably from 1/0.3 to 1/15, more preferably from 1/0.4 to 1/12. Mostpreferably the ratios are about 1/0.5, such as about 1/0.4 or about1/0.6 or about 1/0.7, or about 1/0.8, about 1/2, such as about 1/1.7 orabout 1/2.5, about 1/3, such as about 1/3.3, about 1/5 or about 1/10.

In preferred embodiments of the present invention, amorphic bardoxolonemethyl is employed more preferably in a pharmaceutical formulationcomprising amorphous bardoxolone methyl, preferably obtained asspray-dried dispersion with a glass-forming excipient, such asmethacrylic acid copolymer Type C, USP, e.g. in a 4/6 weight ratio ofbardoxolone methyl to methacrylic acid copolymer Type C, USP (Eurdagit),more preferably admixed with particles comprised of at least onehydrophilic binder, such as hydroxypropylmethylcellulose, according toUS2012/022156. Preferred compositions of bardoxolone methyl according tothe present invention, also contain a surface active ingredient, such assodium lauryl sulfate, preferably in amounts of about 1 to 5 weight %,preferably about 3%, such as 2.73%, of the total composition.

In preferred embodiments, amorphous bardoxolone methyl is administeredaccording to the invention in daily dosages of 0.05 to 1 mg per kg bodyweight, more preferably in dosages of 0.1 to 0.8 mg per kg body weightand most preferably in dosages of 0.2 mg to 0.6 mg per kg body weight,such as in daily dosages of about 0.15 mg, about 0.25 mg or about 0.35mg per kg body weight. Daily oral dosages of about 10 mg, about 20 mg,and about 30 mg bardoxolone methyl per patient are particularlypreferred.

For daily administration of amorphous bardoxolone methyl, the followingdosages are employed per patient: About 2 mg rosiglitazone and about 10mg bardoxolone methyl or about 2 mg rosiglitazone and about 20 mgbardoxolone methyl or about 2 mg rosiglitazone and about 30 mgbardoxolone methyl or about 4 mg rosiglitazone and about 10 mgbardoxolone methyl or about 4 mg rosiglitazone and about 20 mgbardoxolone methyl or about 4 mg rosiglitazone and about 30 mgbardoxolone methyl or about 8 mg rosiglitazone and about 10 mgbardoxolone methyl or about 8 mg rosiglitazone and about 20 mgbardoxolone methyl or about 8 mg rosiglitazone and about 30 mgbardoxolone methyl. Most preferably, about 8 mg rosiglitazone and about20 mg bardoxolone methyl are employed. In particular it is preferred ifthe above amounts are used in a fixed dose combination, i.e. in a solidoral dosage form.

Alternatively, for daily administration or amorphous bardoxolone methyl,the following dosages are employed per patient: About 15 mg pioglitazoneand about 10 mg bardoxolone methyl or about 15 mg pioglitazone and about20 mg bardoxolone methyl or about 15 mg pioglitazone and about 30 mgbardoxolone methyl or about 30 mg pioglitazone and about 10 mgbardoxolone methyl or about 30 mg pioglitazone and about 20 mgbardoxolone methyl or about 30 mg pioglitazone and about 30 mgbardoxolone methyl or about 45 mg pioglitazone and about 10 mgbardoxolone methyl or about 45 mg pioglitazone and about 20 mgbardoxolone methyl or about 45 mg pioglitazone and about 30 mgbardoxolone methyl. Most preferably, about 45 mg pioglitazone and about20 mg bardoxolone methyl are employed. Most preferably, about 8 mgrosiglitazone and about 20 mg bardoxolone methyl are employed. Inparticular it is preferred if the above amounts are used in a fixed dosecombination, i.e. in a solid oral dosage form.

In preferred embodiments of the present invention, where bardoxolonemethyl is employed in amorphic form, preferred ratios betweenrosiglitazone and bardoxolone methyl are from 1/1 to 1/20 (“I” indicates“to” throughout this application, when a ratio is concerned, w/w,rosiglitazone/bardoxolone methyl), preferably from 1/1.1 to 1/17, morepreferably from 1/1.2 to 1/16. Most preferably the ratios are about1/1.3, such as about 1/1.25, about 1/2.5, about 1/3.5, such as 1/3.75,about 1/5, about 7.5, about 1/10.

In further In preferred embodiments of the present invention, wherebardoxolone methyl is employed in amorphic form, preferred ratiosbetween pioglitazone and bardoxolone methyl are from 1/0.1 to 1/3 (w/w,pioglitazone/bardoxolone methyl), preferably from 1/0.15 to 1/2.5, morepreferably from 1/0.2 to 1/2.2. Most preferably the ratios are about1/0.2, such as about 1/0.22, about 1/0.3, such as about 1/0.33, about1/0.4, such as about 1/0.44, about 1/0.7, such as about 1/0.67, about1/1 or about 1/2.

Dosage forms and in particular oral dosage forms such as tablets orcapsules containing both a PPAR gamma agonist and a Nrf2 activator in afixed dose combination comprising the above compositions in the givenratios and especially those containing amorphic bardoxolone methyl, arepreferred.

Fixed dose combinations, such as tablets containing the activeingredients in the above amounts and ratios, are most preferred.

Pharmaceutical compositions provided by the present disclosure maycomprise a therapeutically effective amount of a PPAR gamma agonist andan Nrf2 activator together with a suitable amount of one or morepharmaceutically acceptable vehicles so as to provide a composition forproper administration to a patient. Suitable pharmaceutical vehicles aredescribed in the art.

In certain embodiments, a PPAR gamma agonist and an Nrf2 activator maytogether be incorporated into pharmaceutical compositions to beadministered orally. Oral administration of such pharmaceuticalcompositions may result in uptake of the PPAR gamma agonist and the Nrf2activator throughout the intestine and entry into the systemiccirculation. Such oral compositions may be prepared in a manner known inthe pharmaceutical art and comprise a PPAR gamma agonist and an Nrf2activator and at least one pharmaceutically acceptable vehicle. Oralpharmaceutical compositions may include a therapeutically effectiveamount of a PPAR gamma agonist and an Nrf2 activator and a suitableamount of a pharmaceutically acceptable vehicle, so as to provide anappropriate form for administration to a patient.

A PPAR gamma agonist and an Nrf2 activator may together be incorporatedinto pharmaceutical compositions to be administered by any otherappropriate route of administration including intradermal,intramuscular, intraperitoneal, intravenous, subcutaneous, intranasal,epidural, oral, sublingual, intracerebral, intravaginal, transdermal,rectal, inhalation, or topical.

In one embodiment of the present invention, a topical formulation isprovided, containing a ppar agonist, such as a glitazone likepioglitazone or rosiglitazone and an Nrft2 activator, preferably Nrf2activator that does not or only rarely cause an allergic skin reaction,such as bardoxolone methyl, CDDO, CDDO-IM, CDDO-MA, TP-225, menadione,vitamin K1, BHA, BHT, tBHQ, tBQ, curcumin, reservatrol, cynnamicaldehyde or oltipraz. The topical formulation is preferably used in thetreatment of psoriasis, acne, rosacea and skin rash such as skin rashcaused by EGFR inhibitors like cetuximab, zalutumumab, nimotuzumab, andmatuzumab, gefitinib, erlotinib, and lapatinib. The formulations areprepared with customary ingredients and processes known in the artand/or disclosed herein.

Pharmaceutical compositions comprising a PPAR gamma agonist and an Nrf2activator may be manufactured by means of conventional mixing,dissolving, granulating, dragee-making, levigating, emulsifying,encapsulating, entrapping, or lyophilizing processes. Pharmaceuticalcompositions may be formulated in a conventional manner using one ormore physiologically acceptable carriers, diluents, excipients, orauxiliaries, which facilitate processing of the PPAR gamma agonist andthe Nrf2 activator or crystalline forms thereof and one or morepharmaceutically acceptable vehicles into formulations that can be usedpharmaceutically. Proper formulation is dependent upon the route ofadministration chosen. Pharmaceutical compositions provided by thepresent disclosure may take the form of solutions, suspensions,emulsion, tablets, pills, pellets, capsules, capsules containingliquids, powders, sustained-release formulations, suppositories,emulsions, aerosols, sprays, suspensions, or any other form suitable foradministration to a patient. Pharmaceutical compositions provided by thepresent disclosure may be formulated in a unit dosage form. A unitdosage form refers to a physically discrete unit suitable as a unitarydose for patients undergoing treatment, with each unit containing apredetermined quantity of a PPAR gamma agonist and an Nrf2 activatorcalculated to produce an intended therapeutic effect. A unit dosage formmay be for a single daily dose, for administration 2 times per day, orone of multiple daily doses, e.g., 3 or more times per day. Whenmultiple daily doses are used, a unit dosage form may be the same ordifferent for each dose. One or more dosage forms may comprise a dose,which may be administered to a patient at a single point in time orduring a time interval.

Pharmaceutical compositions comprising a PPAR gamma agonist and an Nrf2activator may be formulated for immediate release or controlled orsustained or delayed release.

In certain embodiments, an oral dosage form provided by the presentdisclosure may be a controlled release dosage form. Controlled deliverytechnologies can improve the absorption of a drug in a particular regionor regions of the gastrointestinal tract. Controlled drug deliverysystems may be designed to deliver a drug in such a way that the druglevel is maintained within a therapeutically effective window andeffective and safe blood levels are maintained for a period as long asthe system continues to deliver the drug with a particular releaseprofile in the gastrointestinal tract. Controlled drug delivery mayproduce substantially constant blood levels of the PPAR gamma agonistand the Nrf2 activator over a period of time as compared to fluctuationsobserved with immediate release dosage forms. For some PPAR gammaagonists and Nrf2 activators, maintaining a constant blood and tissueconcentration throughout the course of therapy is the most desirablemode of treatment. Immediate release of the PPAR gamma agonist and theNrf2 activator may cause blood levels to peak above the level requiredto elicit a desired response, which may waste the agents and may causeor exacerbate toxic side effects. Controlled drug delivery can result inoptimum therapy, and not only can reduce the frequency of dosing, butmay also reduce the severity of side effects. Examples of controlledrelease dosage forms include dissolution controlled systems, diffusioncontrolled systems, ion exchange resins, osmotically controlled systems,erodable matrix systems, pH independent formulations, gastric retentionsystems, and the like.

An appropriate oral dosage form for a particular pharmaceuticalcomposition provided by the present disclosure may depend, at least inpart, on the gastrointestinal absorption properties of the PPAR gammaagonist and the Nrf2 activator and the stability of these agents in thegastrointestinal tract, the pharmacokinetics thereof and the intendedtherapeutic profile. An appropriate controlled release oral dosage formmay be selected for a particular a PPAR gamma agonist and Nrf2activator. For example, gastric retention oral dosage forms may beappropriate for agents absorbed primarily from the uppergastrointestinal tract, and sustained release oral dosage forms may beappropriate for agents absorbed primarily from the lowergastrointestinal tract.

In certain embodiments, pharmaceutical compositions provided by thepresent disclosure may be practiced with dosage forms adapted to providesustained release of a PPAR gamma agonist and an Nrf2 activator uponoral administration. Sustained release oral dosage forms may be used torelease the PPAR gamma agonist and/or the Nrf2 activator over aprolonged time period and are useful when it is desired that an agent bedelivered to the lower gastrointestinal tract. Sustained release oraldosage forms include any oral dosage form that maintains therapeuticconcentrations of the agents in a biological fluid such as the plasma,blood, cerebrospinal fluid, or in a tissue or organ for a prolonged timeperiod. Sustained release oral dosage forms include diffusion-controlledsystems such as reservoir devices and matrix devices,dissolution-controlled systems, osmotic systems, and erosion-controlledsystems. Sustained release oral dosage forms and methods of preparingthe same are well known in the art.

In each of the above dosage forms, the PPAR gamma agonist may beformulated together in admixture or preferably separately from the Nrf2activator. Each of the PPAR gamma agonist and Nrf2 activator maypreferably be contained in separate form within the dosage form, such asan oral dosage form, which is preferably a tablet or capsule. In suchoral dosage form, wherein the PPAR gamma agonist and the Nrf2 activatorare separated, each agent may be formulated with different excipients.The PPAR gamma agonist and the Nrf2 activator may also be each containedin formulations with different release profiles, i.e. with immediate,controlled or delayed release.

The formulations and in particular the solid oral dosage formscontaining a PPAR gamma agonist and/or an Nrf2 activator may contain aconventional additive in the field of pharmaceutical preparation and canbe also produced according to a known method. As the additive, forexample, excipient, disintegrant, binder, lubricant, coloring agent, pHregulator, surfactant, release-sustaining agent, stabilizer, sour agent,flavor, glidant and the like can be mentioned. These additives are usedin an amount conventionally employed in the field of pharmaceuticalpreparation.

As the excipient, for example, starches such as corn starch, potatostarch, wheat starch, rice starch, partly pregelatinized starch,pregelatinized starch, porous starch and the like; sugars and sugaralcohols such as lactose, fructose, glucose, D-mannitol, sorbitol andthe like; anhydrous calcium phosphate, crystalline cellulose,precipitated calcium carbonate, calcium silicate and the like can bementioned.

As the disintegrant, for example, carboxymethyl cellulose, calciumcarboxymethyl cellulose, sodium carboxymethyl starch, croscarmellosesodium, crospovidone, low-substituted hydroxypropyl cellulose,hydroxypropyl starch and the like are used. The amount of thedisintegrant to be used is preferably 0.5-25 parts by weight, morepreferably 1-15 parts by weight, per 100 parts by weight of the solidpreparation.

As the binder, for example, crystalline cellulose, hydroxypropylcellulose, hydroxypropylmethyl cellulose, polyvinylpyrrolidone, gumarabic powder and the like can be mentioned. The amount of the binder tobe used is preferably 0.1-50 parts by weight, more preferably 0.5-40parts by weight, per 100 parts by weight of the solid preparation.

Preferable examples of the lubricant include magnesium stearate, calciumstearate, talc, sucrose esters of fatty acids, sodium stearyl fumarateand the like. As the coloring agent, for example, food colors such asFood Yellow No. 5, Food Red No. 2, Food Blue No. 2 and the like, foodlake colors, ferric oxide and the like can be mentioned. As the pHregulator, citrate, phosphate, carbonate, tartrate, fumarate, acetate,amino acid salt and the like can be mentioned. As the surfactant, sodiumlauryl sulfate, polysorbate 80, polyoxyethylene (160) polyoxypropylene(30) glycol and the like can be mentioned.

As the release-sustaining agent, for example, cellulose polymers such ashydroxypropyl cellulose, hydroxypropylmethyl cellulose (preferablyhydroxypropylmethyl cellulose 2910, hydroxypropylmethyl cellulose 2208and the like), cellulose acetate (preferably cellulose acetate having anacetyl content of 39.3-40%), cellulose diacetate, cellulose triacetate,cellulose acetate propionate, ethyl cellulose, sodium carboxymethylcellulose, crystalline cellulose sodium carboxymethyl cellulose and thelike; sodium alginate, carboxyvinyl polymer; acrylic acid polymers suchas aminoalkylmethacrylate copolymer RS [Eudragit RS (trademark), RohmPharma], ethyl acrylate-methyl methacrylate copolymer suspension[Eudragit NE (trademark), Rohm Pharma] and the like; and the like can bementioned. The release-sustaining agent may contain, for example, fluxenhancers (e.g., sodium chloride, potassium chloride, sucrose, sorbitol,D-mannitol, polyethylene glycol (preferably polyethylene glycol 400 andthe like), propylene glycol, hydroxypropyl cellulose,hydroxypropylmethyl cellulose, hydroxypropylmethyl cellulose phthalate,cellulose acetate phthalate, polyvinyl alcohol, methacrylic acidpolymer), plasticizers (e.g., triacetin, acetylated monoglyceride, grapeseed oil, olive oil, sesame oil, acetyltributyl citrate, acetyltriethylcitrate, glycerin sorbitol, diethyl oxalate, diethyl maleate, diethylfumarate, dibutyl succinate, diethyl malonate, dioctyl phthalate,dibutyl sebacate, triethyl citrate, tributyl citrate, glyceroltributyrate) and the like. Preferable examples of the release-sustainingagent include (1) a semipermeable membrane coating containing celluloseacetate (preferably cellulose acetate having an acetyl content of39.3-40%), polyethylene glycol (preferably polyethylene glycol 400 andthe like) and triacetin; (2) a release-sustaining composition containingsodium carboxymethyl cellulose, hydroxypropylmethyl cellulose 2910,hydroxypropylmethyl cellulose 2208 and microcrystalline cellulose; andthe like.

As the stabilizer, for example, tocopherol, tetrasodium edetate,nicotinamide, cyclodextrins and the like can be mentioned. As the souragent, for example, ascorbic acid, citric acid, tartaric acid, malicacid and the like can be mentioned. As the flavor, for example, menthol,peppermint oil, lemon oil, vanillin and the like can be mentioned. Asthe glidant, for example, light anhydrous silicic acid, hydrated silicondioxide and the like can be mentioned. The above-mentioned additives maybe used in a mixture of two or more kinds thereof in an appropriateratio.

Use

An appropriate dose of each a PPAR gamma agonist and Nrf2 activator maybe determined based on several factors, including, for example, the bodyweight and/or condition of the patient being treated, the severity ofthe disease being treated, the incidence and/or severity of sideeffects, the manner of administration, and the judgment of theprescribing physician. Appropriate dose ranges may be determined bymethods known to those skilled in the art.

In one embodiment the invention provides a combination of an Nrf2activator and a PPAR gamma agonist for use in the treatment ofinflammatory and autoimmune diseases.

In another embodiment, the invention provides a PPAR gamma agonist foruse in combination with a fumaric acid mono- and/or diester,characterized in that the PPAR gamma agonist is selective and has nosubstantial activity on PPAR alpha or delta.

A therapeutically effective amount of a combination of a PPAR gammaagonist and an Nrf2 activator may be administered as a treatment orpreventative measure to a patient having a predisposition for and/orhistory of immunological, autoimmune, and/or inflammatory diseasesincluding psoriasis, asthma and chronic obstructive pulmonary diseases,cardiac insufficiency including left ventricular insufficiency,myocardial infarction and angina pectoris, mitochondrial andneurodegenerative diseases such as Parkinson's disease, Alzheimer'sdisease, Huntington's disease, retinopathia pigmentosa and mitochondrialencephalomyopathy, transplantation rejection, autoimmune diseasesincluding multiple sclerosis, ischemia and reperfusion injury, advancedglycation endproducts (AGE)-induced genome and protein damage,inflammatory bowel diseases such as Crohn's disease and ulcerativecolitis, thyroid eye disease-related inflammation, fibrosis, such aslung fibrosis, chronic lymphocytic leukemia, aphthous stomatitis, suchas recurrent aphthous stomatitis, acute lung injury, non-alcoholicsteatohepatitis acute renal injury and aging-related progressive renalinjury, diabetic cardiomyopathy and nephropathy. Chronic kidney disease(CKD), Atherosclerosis, hypercholesterolemia, hyperlipidemia, aorticstenosis, acute kidney injury (AKI) after surgery. The present inventioncan also be used in the prevention of cardiovascular disease, for plaquestabilization, reduction of inflammation, reversal of endothelialdysfunction, and decreased thrombogenicity and wound healing indiabetes. Moreover, the combination treatment of the present inventioncan be used in the treatment and prevention of atopic dermatitis,dementia, gastritis, fibrosis, insulin resistance, type I and type IIdiabetes and Syndrome X.

In one embodiment of the present invention, the combination treatment ispreferably used in the prophylaxis or treatment of polycystic ovarysyndrome (PCOS). It can also be found that compounds being both, PPARgamma agonists and Nrf2 activators, show suitable effects as amonotherapeutic agent. Preferred compounds which can be used in theprophylaxis and treatment of PCOS as a single active ingredient in adosage form such as a tablet, are bardoxolone methyl, CDDO, CDDO-IM,CDDO-MA or TP-225. Thus, another object of the present invention is theuse of bardoxolone methyl, CDDO, CDDO-IM, CDDO-MA or TP-225 in theprophylaxis and treatment of PCOS and a method of treating PCOS byadministration of a pharmacologically effective amount of bardoxolonemethyl, CDDO, CDDO-1M, CDDO-MA or TP-225 to a patient in need thereof.In many instances, the mono-therapy with the aforementioned Nrf2activators can be further improved with co-administration of a PPARagonist, such as a glitazone like pioglitazone or rosiglitazone.

NF-κB mediated and/or other diseases are described in the following.

According to another embodiment of the invention, the administration orco-administration of a combination of a PPAR gamma agonist and an Nrf2activator is effective for treating a member of the group of diseasesconsisting of a neurological disorder, an ophthalmological disorder, ina mammal, including, without limitation, a human. According to anotherembodiment the neurological disorder, an ophthalmological disorder, or acombination thereof results from at least one member of the groupconsisting of trauma, ischemia, and hypoxia. According to anotherembodiment the neurological disorder, ophthalmological disorder, orcombination thereof is selected from the group consisting of painfulneuropathy, neuropathic pain, diabetic neuropathy, drug dependence, drugaddition, drug withdrawal, nicotine withdrawal, opiate tolerance, opiatewithdrawal, depression, anxiety, a movement disorder, tardivedyskinesia, a cerebral infection that disrupts the blood-brain barrier,meningitis, meningoencephalitis, stroke, hypoglycemia, cardiac arrest,spinal cord trauma, head trauma, perinatal hypoxia, cardiac arrest,hypoglycemic neuronal damage, glaucoma, retinal ischemia, ischemic opticneuropathy, macular degeneration, multiple sclerosis, sequalae ofhyperhomocystinemia, convulsion, pain, schizophrenia, muscle spasm,migraine headache, urinary incontinence, emesis, brain edema, tardivedyskinesia, AIDS-induced dementia, ocular damage, retinopathy, acognitive disorder, and a neuronal injury associated with HIV infection.According to another embodiment the neurological disorder,ophthalmological disorder, or combination thereof is selected from thegroup consisting of epilepsy, Alzheimer's disease, vascular(multi-infarct) dementia, Huntington's disease, Parkinsonism, multiplesclerosis, amyotrophic lateral sclerosis, and minimal cognitiveimpairment (MCI).

Psoriasis is characterized by hyperkeratosis and thickening of theepidermis as well as by increased vascularity and infiltration ofinflammatory cells in the dermis. Psoriasis vulgaris manifests assilvery, scaly, erythematous plaques on typically the scalp, elbows,knees, and buttocks. Guttate psoriasis occurs as tear-drop size lesions.Fumaric acid esters are recognized for the treatment of psoriasis anddimethyl fumarate is approved for the systemic treatment of psoriasis inGermany (Mrowietz and Asadullah, Trends MoI Med 2005, 11(1), 43-48; andMrowietz et al., Br J Dermatology 1999, 141, 424-429). Efficacy fortreating psoriasis can be determined using animal models and in clinicaltrials. Contrary to fumaric acid esters, it has been found that PPARgamma agonists are not advantageous in the treatment of psoriasis(Placebo response in two long-term randomized psoriasis studies that arenegative for rosiglitazone. Am J Clin Dermatol. 2007; 8(2):93-102).Contrary to this result, it can be found that PPAR gamma agonist providetherapeutic benefit in a combined treatment of psoriasis according tothe present invention.

Inflammatory arthritis includes diseases such as rheumatoid arthritis,juvenile rheumatoid arthritis (juvenile idiopathic arthritis), psoriaticarthritis, and ankylosing spondylitis produce joint inflammation. Thepathogenesis of immune-mediated inflammatory diseases includinginflammatory arthritis is believed to involve TNF and NK-κB signalingpathways (Tracey et al., Pharmacology & Therapeutics 2008, 117,244-279). Dimethyl fumarate has been shown to inhibit TNF andinflammatory diseases including inflammatory arthritis are believed toinvolve TNF and NK-κB signaling and therefore may be useful in treatinginflammatory arthritis (Lowewe et al., J Immunology 2002, 168,4781-4787).

Preferably the inventive method of treatment and combinations can beused in the prophylaxis and treatment of neurodegenerative diseases,such as multiple sclerosis, Parkinson's disease, Alzheimer's disease,Huntington's disease, dementia, mitochondrial encephalomyopathy andamyotrophic lateral sclerosis (ALS).

Multiple sclerosis (MS) is an inflammatory autoimmune disease of thecentral nervous system caused by an autoimmune attack against theisolating axonal myelin sheets of the central nervous system.Demyelination leads to the breakdown of conduction and to severe diseasewith destruction of local axons and irreversible neuronal cell death.The symptoms of MS are highly varied with each individual patientexhibiting a particular pattern of motor, sensible, and sensorydisturbances. MS is typified pathologically by multiple inflammatoryfoci, plaques of demyelination, gliosis, and axonal pathology within thebrain and spinal cord, all of which contribute to the clinicalmanifestations of neurological disability (see e.g., Wingerchuk, LabInvest 2001, 81, 263-281; and Virley, NeuroRx 2005, 2(4), 638-649).Although the causal events that precipitate MS are not fully understood,evidence implicates an autoimmune etiology together with environmentalfactors, as well as specific genetic predispositions. Functionalimpairment, disability, and handicap are expressed as paralysis, sensoryand octintive disturbances spasticity, tremor, a lack of coordination,and visual impairment, which impact on the quality of life of theindividual. The clinical course of MS can vary from individual toindividual, but invariably the disease can be categorized in threeforms: relapsing-remitting, secondary progressive, and primaryprogressive.

Studies support the efficacy of fumaric acid esters for treating MS andhave undergone phase II clinical testing (Schimrigk et al., Eur JNeurology 2006, 13, 604-610; and Wakkee and Thio, Current OpinionInvestigational Drugs 2007, 8(11), 955-962). Assessment of MS treatmentefficacy in clinical trials can be accomplished using tools such as theExpanded Disability Status Scale and the MS Functional as well asmagnetic resonance imaging lesion load, biomarkers, and self-reportedquality of life. Animal models of MS shown to be useful to identify andvalidate potential therapeutics include experimental autoimmune/allergicencephalomyelitis (EAE) rodent models that simulate the clinical andpathological manifestations of MS and nonhuman primate EAE models.

Inflammatory Bowel Disease (Crohn's Disease, Ulcerative Colitis)Inflammatory bowel disease (IBD) is a group of inflammatory conditionsof the large intestine and in some cases, the small intestine thatincludes Crohn's disease and ulcerative colitis. Crohn's disease, whichis characterized by areas of inflammation with areas of normal lining inbetween, can affect any part of the gastrointestinal tract from themouth to the anus. The main gastrointestinal symptoms are abdominalpain, diarrhea, constipation, vomiting, weight loss, and/or weight gain.Crohn's disease can also cause skin rashes, arthritis, and inflammationof the eye. Ulcerative colitis is characterized by ulcers or open soresin the large intestine or colon. The main symptom of ulcerative colitisis typically constant diarrhea with mixed blood of gradual onset. Othertypes of intestinal bowel disease include collagenous colitis,lymphocytic colitis, ischaemic colitis, diversion colitis, Behcet'scolitis, and indeterminate colitis.

Asthma is reversible airway obstruction in which the airway occasionallyconstricts, becomes inflamed, and is lined with an excessive amount ofmucus. Symptoms of asthma include dyspnea, wheezing, chest tightness,and cough. Asthma episodes may be induced by airborne allergens, foodallergies, medications, inhaled irritants, physical exercise,respiratory infection, psychological stress, hormonal changes, coldweather, or other factors.

As shown in animal studies (Joshi et al., US 2007/0027076) fumaric acidesters may be useful in treating pulmonary diseases such as asthma andchronic obstructive pulmonary disorder.

Chronic obstructive pulmonary disease (COPD), also known as chronicobstructive airway disease, is a group of diseases characterized by thepathological limitation of airflow in the airway that is not fullyreversible, and includes conditions such as chronic bronchitis,emphysema, as well as other lung disorders such as asbestosis,pneumoconiosis, and pulmonary neoplasms {see, e.g., Barnes,Pharmacological Reviews 2004, 56(4), 515-548). The airflow limitation isusually progressive and associated with an abnormal inflammatoryresponse of the lungs to noxious particles and gases. COPD ischaracterized by a shortness of breath the last for months or years,possibly accompanied by wheezing, and a persistent cough with sputumproduction. COPD is most often caused by tobacco smoking, although itcan also be caused by other airborne irritants such as coal dust,asbestos, urban pollution, or solvents. COPD encompasses chronicobstructive bronchiolitis with fibrosis and obstruction of smallairways, and emphysema with enlargement of airspaces and destruction oflung parenchyma, loss of lung elasticity, and closure of small airways.

Neurodegenerative diseases such as Parkinson's disease, Alzheimer'sdisease, Huntington's disease and amyoptrophic lateral sclerosis arecharacterized by progressive dysfunction and neuronal death.

Parkinson's disease is a slowly progressive degenerative disorder of thenervous system characterized by tremor when muscles are at rest (restingtremor), slowness of voluntary movements, and increased muscle tone(rigidity). In Parkinson's disease, nerve cells in the basal ganglia,e.g., substantia nigra, degenerate, and thereby reduce the production ofdopamine and the number of connections between nerve cells in the basalganglia. As a result, the basal ganglia are unable to smooth musclemovements and coordinate changes in posture as normal, leading totremor, incoordination, and slowed, reduced movement (bradykinesia)(Blandini, et al., Mol. Neurobiol. 1996, 12, 73-94).

Alzheimer's disease is a progressive loss of mental functioncharacterized by degeneration of brain tissue, including loss of nervecells and the development of senile plaques and neurofibrillary tangles.In Alzheimer's disease, parts of the brain degenerate, destroying nervecells and reducing the responsiveness of the maintaining neurons toneurotransmitters. Abnormalities in brain tissue consist of senile orneuritic plaques, e.g., clumps of dead nerve cells containing anabnormal, insoluble protein called amyloid, and neurofibrillary tangles,twisted strands of insoluble proteins in the nerve cell.

Huntington's disease is an autosomal dominant neurodegenerative disorderin which specific cell death occurs in the neostriatum and cortex(Martin, N Engl J Med 1999, 340, 1970-80). Onset usually occurs duringthe fourth or fifth decade of life, with a mean survival at age of onsetof 14 to 20 years. Huntington's disease is universally fatal, and thereis no effective treatment. Symptoms include a characteristic movementdisorder (Huntington's chorea), cognitive dysfunction, and psychiatricsymptoms. The disease is caused by a mutation encoding an abnormalexpansion of CAG-encoded polyglutamine repeats in the protein,huntingtin.

Amyotrophic lateral sclerosis (ALS) is a progressive neurodegenerativedisorder characterized by the progressive and specific loss of motorneurons in the brain, brain stem, and spinal cord (Rowland andSchneider, N Engl J Med 2001, 344, 1688-1700). ALS begins with weakness,often in the hands and less frequently in the feet that generallyprogresses up an arm or leg. Over time, weakness increases andspasticity develops characterized by muscle twitching and tightening,followed by muscle spasms and possibly tremors. The average age of onsetis 55 years, and the average life expectancy after the clinical onset is4 years. The only recognized treatment for ALS is riluzole, which canextend survival by only about three months.

Myasthenia gravis (MG) is a classic autoimmune disease affectingneuromuscular junctions of striated muscle. Immunization of differentanimal species with acetylcholine receptor (AChR) and complete Freund'sadjuvant (CFA) results in an animal model of MG named experimentalautoimmune myasthenia gravis (EAMG).

Alopecia greata is a common disease, but for ethical reasons it seemsdifficult to perform large-scale studies to elucidate the pathogenesisand to develop new therapeutic approaches in man. It is thereforehelpful to develop appropriate animal models. The Dundee experimentalbald rat (DEBR) and the C3H/HeJ mouse are well-established animal modelsfor alopecia greata and can be used for the study of genetic aspects,pathogenesis and therapy of the disease (J Dtsch Dermatol Ges. 2004April; 2(4):260-73).

A mouse model for diabetic nephropathy can be utilized according toKidney International 77, 749-750 (May 2010), in order to prove theeffect of the combination according to the present invention.

Thus, diseases and conditions for which treatment with the combinationof a PPAR gamma agonist and an Nrf2 activator can be useful, includerheumatica, granuloma annulare, lupus, autoimmune carditis, eczema,sarcoidosis, and autoimmune diseases including acute disseminatedencephalomyelitis, Addison's disease, alopecia greata, ankylosingspondylitis, antiphospholipid antibody syndrome, autoimmune hemolyticanemia, autoimmune hepatitis, autoimmune inner ear disease, bullouspemphigoid, Behcet's disease, celiac disease, Chagas disease, chronicobstructive pulmonary disease, Crohn's disease, dermatomyositis,diabetes mellitus type I, endometriosis, Goodpasture's syndrome, Graves'disease, Guillain-Barre syndrome, Hashimoto's disease, hidradenitissuppurativea, Kawasaki disease, IgA neuropathy, idiopathicthrombocytopenic purpura, interstitial cystitis, lupus erythematosus,mixed connective tissue disease, morphea, multiple sclerosis, myastheniagravis, narcolepsy, neuromyotonia, pemphigus vulgaris, perniciousanaemia, psoriasis, psoriatic arthritis, polymyositis, primary biliarycirrhosis, rheumatoid arthritis, schizophrena, scleroderma, Sjogren'ssyndrome, stiff person syndrome, temporal arteritis, ulcerative colitis,vasculitis, vitiligo, and Wegener's granulomatosis.

Administration

The combination of an Nrf2 activator and a PPAR gamma agonist andpharmaceutical compositions thereof may be administered orally or by anyother appropriate route, for example, by infusion or bolus injection, byabsorption through epithelial or mucocutaneous linings (e.g., oralmucosa, rectal, and intestinal mucosa, etc.). Other suitable routes ofadministration include, but are not limited to, intradermal,intramuscular, intraperitoneal, intravenous, subcutaneous, intranasal,epidural, oral, sublingual, intracerebral, intravaginal, transdermal,rectal, inhalation, or topical.

Administration may be systemic or local. Various delivery systems areknown, e.g., encapsulation in liposomes, microparticles, microcapsules,capsules, etc., that may be used to administer a compound and/orpharmaceutical composition.

For systemic administration, a therapeutically effective dose may beestimated initially from in vitro assays. For example, a dose may beformulated in animal models to achieve a beneficial circulatingcomposition concentration range. Initial doses may also be estimatedfrom in vivo data, e.g., animal models, using techniques that are knownin the art. Such information may be used to more accurately determineuseful doses in humans. One having ordinary skill in the art mayoptimize administration to humans based on animal data.

The embodiment “PPAR gamma agonist for use in combination with a fumaricacid mono- and/or diester in the treatment of an autoimmune and/orinflammatory disease” relates to a method of use of at least one PPARgamma agonist in combination with a fumaric acid mono- and/or diester inthe treatment of an autoimmune and/or inflammatory disease.

Preferred embodiments of the invention are described in the following:

1. PPAR gamma agonist for use in combination with a fumaric acid mono-and/or diester in the treatment of an autoimmune and/or inflammatorydisease.

2. PPAR gamma agonist such as rosiglitazone, for use in combination witha fumaric acid mono- and/or diester according to embodiment 1,characterized in that the autoimmune and/or inflammatory disease ispsoriasis.

3. PPAR gamma agonist for use in combination with a fumaric acid mono-and/or diester according to embodiment 1, characterized in that theautoimmune and/or inflammatory disease is selected from the group ofpsoriatic arthritis, multiple sclerosis, inflammatory bowel disease(IBS), colitis ulcerosa, Crohn's disease, hepatitis, effluvium,allopecia greata, cicatricial alopecia, diabetic nephrophathy, CKD andmyasthenia gravis.

4. PPAR gamma agonist for use in combination with a fumaric acid mono-and/or diester, according to the aforementioned embodiments,characterized in that the PPAR gamma agonist is selected from the groupof rosiglitazone, pioglitazone, troglitazone and ciglitazone.

5. PPAR gamma agonist for use in combination with a fumaric acid mono-and/or diester, according to the aforementioned embodiments,characterized in that the fumaric acid mono- and/or diester is selectedfrom the group of monomethyl hydrogen fumarate, dimethyl fumarate,monoethyl hydrogen fumarate and diethyl fumarate.

6. A pharmaceutical composition comprising a PPAR gamma agonist and afumaric acid mono- and/or diester and optionally one or more excipients.

7. A pharmaceutical composition comprising rosiglitazone, pioglitazone,troglitazone or ciglitazone and a fumaric acid mono- and/or diester andoptionally one or more excipients.

8. A pharmaceutical composition according to embodiments 6 or 7,characterized in that the fumaric acid mono- and/or diester is selectedfrom the group of monomethyl hydrogen fumarate, dimethyl fumarate,monoethyl hydrogen fumarate, and diethyl fumarate.

9. A solid oral dosage form comprising a PPAR gamma agonist and afumaric acid mono- and/or diester.

10. A solid oral dosage form comprising rosiglitazone, pioglitazone,troglitazone or ciglitazone as a PPAR gamma agonist and a fumaric acidmono- and/or diester.

11. A solid oral dosage form according to embodiments 9 or 10,characterized in that the fumaric acid mono- and/or diester is selectedfrom the group of monomethyl hydrogen fumarate, dimethyl fumarate,monoethyl hydrogen fumarate, and diethyl fumarate.

12. A solid oral dosage form according to embodiments 9 to 10,characterized in that the PPAR gamma agonist and the fumaric acid mono-and/or diester are each contained in the dosage form in a separatecomposition optionally containing one or more excipients.

13. Kit of parts comprising a) a PPAR gamma agonist and b) a fumaricacid mono- and/or diester and optionally c) instructions for a dosingregime.

14. Kit of parts comprising a) rosiglitazone, pioglitazone, troglitazoneor ciglitazone b) a fumaric acid mono- and/or diester and optionally c)instructions for a dosing regime.

15. Kit of parts according to embodiments 13 or 14, characterized inthat the fumaric acid mono- and/or diester is selected from the group ofmonomethyl hydrogen fumarate, dimethyl fumarate, monoethyl hydrogenfumarate, and diethyl fumarate.

16. PPAR gamma agonist for use in combination with an Nrf2 activatorselected from the group of monoalkyl hydrogen fumarate, dialkyl fumarateand bardoxolone alkyl in the treatment of multiple sclerosis.

17. PPAR gamma agonist for use in combination with an Nrf2 activatoraccording to the foregoing embodiment, characterized in that multiplesclerosis includes relapsing-remitting (RR), secondary progressive (SP),primary progressive (PP) and progressive relapsing (PR) multiplesclerosis and the first demyelinating event suggestive of MS orclinically isolated syndrome (CIS).

18. PPAR gamma agonist for use in combination with an Nrf2 activatoraccording to the foregoing embodiments, characterized in that the PPARgamma agonist is a glitazone.

19. PPAR gamma agonist for use in combination with an Nrf2 activatoraccording to the foregoing embodiments, characterized in that the PPARgamma agonist is a glitazone selected from the group of pioglitazone androsiglitazone.

20. PPAR gamma agonist for use in combination with an Nrf2 activatoraccording to the foregoing embodiments, characterized in that Nrf2activator selected from the group of monomethyl hydrogen fumarate,dimethyl fumarate and bardoxolone methyl.

21. PPAR gamma agonist for use in combination with an Nrf2 activatoraccording to the foregoing embodiments, characterized in that ratiosbetween rosiglitazone and dimethyl fumarate are selected from 1/20 to1/400 (w/w, rosiglitazone/dimethyl fumarate).

22. PPAR gamma agonist for use in combination with an Nrf2 activatoraccording to the foregoing embodiments, characterized in that ratiosbetween pioglitazone and dimethyl fumarate are selected from 1/3 to 1/60(w/w, pioglitazone/dimethyl fumarate).

23. PPAR gamma agonist for use in combination with an Nrf2 activatoraccording to the foregoing embodiments, characterized in that ratiosbetween rosiglitazone and bardoxolone methyl are selected from 1/1 to1/100 (w/w, rosiglitazone/bardoxolone methyl).

24. PPAR gamma agonist for use in combination with an Nrf2 activatoraccording to the foregoing embodiments, characterized in thatbardoxolone methyl is employed in amorphic form and ratios betweenrosiglitazone and bardoxolone methyl are from 1/1 to 1/20 (w/w,rosiglitazone/bardoxolone methyl).

25. PPAR gamma agonist for use in combination with an Nrf2 activatoraccording to the foregoing embodiments, characterized in that ratiosbetween pioglitazone and bardoxolone methyl are selected from 1/0.1 to1/20 (w/w, pioglitazone/bardoxolone methyl).

26. PPAR gamma agonist for use in combination with an Nrf2 activatoraccording to the foregoing embodiments, characterized in thatbardoxolone methyl is employed in amorphic form and ratios betweenpioglitazone and bardoxolone methyl are from 1/0.1 to 1/3 (w/w,pioglitazone/bardoxolone methyl).

27. A pharmaceutical composition comprising a PPAR gamma agonist and anNrf2 activator selected from the group of monoalkyl hydrogen fumarate,dialkyl fumarate and bardoxolone alkyl and optionally one or moreexcipients.

28. A pharmaceutical composition according to embodiment 27,characterized in that the PPAR gamma agonist is a glitazone.

29. A pharmaceutical composition according to embodiment 28,characterized in that the glitazone is selected from the group ofpioglitazone and rosiglitazone.

30. A pharmaceutical composition according to embodiments 28 to 30,characterized in that Nrf2 activator selected from the group ofmonomethyl hydrogen fumarate, dimethyl fumarate and bardoxolone methyl.

31. A pharmaceutical composition according to embodiments 28 to 30,characterized in that ratios between rosiglitazone and dimethyl fumarateare selected from 1/20 to 1/400 (w/w, rosiglitazone/dimethyl fumarate).

32. A pharmaceutical composition according to embodiments 28 to 30,characterized in that ratios between pioglitazone and dimethyl fumarateare selected from 1/3 to 1/60 (w/w, ioglitazone/dimethyl fumarate).

33. A pharmaceutical composition according to embodiments 28 to 30,characterized in that ratios between rosiglitazone and bardoxolonemethyl are selected from 1/1 to 1/100 (w/w, rosiglitazone/bardoxolonemethyl).

34. A pharmaceutical composition according to embodiments 28 to 30,characterized in that bardoxolone methyl is employed in amorphic formand ratios between rosiglitazone and bardoxolone methyl are from 1/1 to1/20 (w/w, rosiglitazone/bardoxolone methyl). 35. A pharmaceuticalcomposition according to embodiments 28 to 30, characterized in thatratios between pioglitazone and bardoxolone methyl are selected from1/0.1 to 1/20 (w/w, pioglitazone/bardoxolone methyl).

36. A pharmaceutical composition according to embodiments 28 to 30,characterized in bardoxolone methyl is employed in amorphic form andratios between pioglitazone and bardoxolone methyl are from 1/0.1 to 1/3(w/w, pioglitazone/bardoxolone methyl).

37. A solid oral dosage form comprising the pharmaceutical compositionaccording to embodiments 27 to 36.

38. A solid oral dosage form comprising a PPAR gamma agonist and an Nrf2activator selected from the group of monoalkyl hydrogen fumarate,dialkyl fumarate and bardoxolone alkyl and optionally one or moreexcipients, wherein the PPAR gamma agonist and the Nrf2 activator areeach contained in a separate pharmaceutical formulation.

39. A solid oral dosage form according to embodiment 38, wherein thePPAR gamma agonist is a glitazone and the Nrf2 activator is selectedfrom the group of monomethyl hydrogen fumarate, dimethyl fumarate andbardoxolone methyl.

40. A solid oral dosage form according to the aforementionedembodiments, wherein the Nrf2 activator is bardoxolone methyl containedin an amorphous form.

41. A solid oral dosage form according to the aforementionedembodiments, wherein the Nrf2 activator is bardoxolone methyl containedin an amorphous dispersion formulation.

42. A solid oral dosage form according to the aforementionedembodiments, wherein the Nrf2 activator is bardoxolone methyl containedin an amorphous dispersion formulation obtained by spray drying orfreeze drying.

43. A solid oral dosage form according to the aforementionedembodiments, wherein the Nrf2 activator is bardoxolone methyl containedin an amorphous dispersion formulation with methacrylic acid copolymerType C, USP.

44. A solid oral dosage form according to the aforementionedembodiments, wherein the Nrf2 activator is bardoxolone methyl containedin an amorphous dispersion formulation with methacrylic acid copolymerType C, USP in a weight ratio of 4/6.

45. A solid oral dosage form according to the aforementionedembodiments, wherein the Nrf2 activator is bardoxolone methyl containedin an amorphous dispersion formulation comprising at least onehydrophilic binder.

46. A solid oral dosage form according to the aforementionedembodiments, wherein the hydrophilic binder is employed in an amount ofbetween about 1 and about 40% (weight % of the total pharmaceuticalcomposition used for the dosage form), preferably between about 2 toabout 20%, more preferably between about 4 and about 10% even morepreferably between about 5 and about 7.5% and most preferred betweenabout 7 and 7.5%, such as about 7%.

47. A solid oral dosage form according to the aforementionedembodiments, wherein the hydrophilic binder ishydroxypropylmethylcellulose.

48. A solid oral dosage form according to the aforementionedembodiments, wherein the Nrf2 activator is bardoxolone methyl containedin an amorphous dispersion formulation and wherein the dosage form alsocontains a surface active agent, such as sodium lauryl sulfate,preferably in an amount of about 3% of the total weight of the dosageform.

49. Kit of parts comprising a) a PPAR gamma agonist and b) an Nrf2activator selected from the group of monoalkyl hydrogen fumarate,dialkyl fumarate and bardoxolone alkyl and optionally c) instructionsfor a dosing regime.

50. Kit of parts comprising a) a PPAR agonist and b) an Nrf2 activatorselected from the group of monoalkyl hydrogen fumarate, dialkyl fumarateand bardoxolone alkyl and optionally c) instructions for a dosingregime.

51. Kit of parts according to the foregoing embodiment, characterized inthat the PPAR gamma agonist is rosiglitazone or pioglitazone.

52. Kit of parts according to the foregoing embodiment, characterized inthat the Nrf2 activator is dimethyl fumarate or bardoxolone methyl.

53. PPAR gamma agonist for use in combination with an Nrf2 activator forthe treatment of multiple sclerosis according to the foregoingembodiments, wherein said PPAR agonist is administered to a patientsimultaneously with or up to 2 days before or after an Nrf2 activator,such as those selected from the group of monoalkyl hydrogen fumarate,dialkyl fumarate and bardoxolone alkyl, is administered to said patient.

54. PPAR gamma agonist for use in combination with an Nrf2 activator forthe treatment of multiple sclerosis according to the foregoingembodiments, wherein said PPAR agonist is administered once or twicedaily.

55. PPAR gamma agonist for use in combination with an Nrf2 activator forthe treatment of multiple sclerosis according to the foregoingembodiments, wherein said Nrf2 activator is administered once or twicedaily.

56. PPAR gamma agonist for use in combination with an Nrf2 activator inthe treatment of autoimmune and/or inflammatory diseases other thanpsoriasis.

57. PPAR gamma agonist, preferably other than pioglitazone, for use incombination with an Nrf2 activator belonging to a different chemicalclass, in the treatment of autoimmune and/or inflammatory diseases, suchas multiple sclerosis, psoriasis or chronic kidney disease.

58. PPAR gamma agonist, preferably other than pioglitazone, for useaccording to the aforementioned embodiment, wherein the Nrf2 activatorhaving no significant PPAR gamma agonistic effect.

59. PPAR gamma agonist, preferably other than pioglitazone, having nosignificant activating effect on Nrf2, for use in combination with anNrf2 activator having no significant PPAR gamma agonistic effect, in thetreatment of autoimmune and/or inflammatory diseases, such as multiplesclerosis, psoriasis or chronic kidney disease.

60. PPAR gamma agonist, preferably other than pioglitazone, for use incombination with an Nrf2 activator belonging to different chemicalclass, wherein the Nrf2 activator is other than bardoxolone methyl andits derivatives, in the treatment of autoimmune and/or inflammatorydiseases, such as multiple sclerosis, psoriasis or chronic kidneydisease.

61. Composition comprising a PPAR gamma agonist and an Nrf2 activatorbelonging to a different chemical class, for use in the treatment ofautoimmune and/or inflammatory diseases, such as multiple sclerosis,psoriasis or chronic kidney disease.

62. Composition according to the aforementioned embodiment, comprising aPPAR gamma agonist having no significant activating effect on Nrf2, andan Nrf2 activator having no significant PPAR gamma agonistic effect, foruse in the treatment of autoimmune and/or inflammatory diseases, such asmultiple sclerosis, psoriasis or chronic kidney disease.

63. Composition comprising a PPAR gamma agonist, such as pioglitazoneand an Nrf2 activator.

64. Composition comprising a PPAR gamma agonist, such as pioglitazoneand an Nrf2 activator having no significant PPAR gamma agonistic effect.

65. Composition comprising pioglitazone and an Nrf2 activator having nosignificant PPAR gamma agonistic effect, for use in the treatment ofpsoriasis and other autoimmune and/or inflammatory diseases, such asmultiple sclerosis, psoriasis or chronic kidney disease.

66. PPAR gamma agonist for use in combination with an Nrf2 activatorhaving no significant PPAR gamma agonistic effect, in the treatment ofmultiple sclerosis.

67. PPAR gamma agonist for use in combination with an Nrf2 activatorother than bardoxolone methyl, in the treatment of CKD or multiplesclerosis.

68. PPAR gamma agonist for use in combination with an Nrf2 activatoraccording to the foregoing embodiment, characterized in that multiplesclerosis includes relapsing-remitting (RR), secondary progressive (SP),primary progressive (PP) and progressive relapsing (PR) multiplesclerosis and the first demyelinating event suggestive of MS orclinically isolated syndrome (CIS).

69. PPAR gamma agonist for use in combination with an Nrf2 activatoraccording to the foregoing embodiments, characterized in that the PPARgamma agonist is a glitazone.

70. PPAR gamma agonist for use in combination with an Nrf2 activatoraccording to any of the foregoing embodiments, characterized in that thePPAR gamma agonist is a glitazone selected from the group ofpioglitazone and rosiglitazone.

71. PPAR gamma agonist for use in combination with an Nrf2 activatoraccording to any of the foregoing embodiments, characterized in that theNrf2 activator is selected chemical compounds belonging to the group ofMichael reaction acceptors, phenols, diphenols, chalcones,isothiocyanates, thiocarbamates, quinones, naphtoquinones and 1,2dithiole-3-thiones, wherein one or more, preferably 1, 2, 3, 4, 5, 6 or7 H-atoms may be substituted by linear or branched alkyl andperfluoroalkyl, such as methyl, ethyl, trifluoromethyl, halogen such asBr, Cl F or I, hydroxy, alkoxy and perfluoroalkoxy, such as methoxy,ethoxy, trifluoromethoxy, cyano and nitro, which chemical compounds havenot more than one or two 5- or 6-membered carbocyclic rings or 5- or6-membered heterocyclic rings having 1, 2 or 3 N-, O or S-atoms as ringatoms which rings may be fused to each other or preferably no or onlyone carbocyclic or heterocyclic ring. Compositions containing these Nrf2activators are preferred.

Preferred Nrf2 activators for use in combination according to theinvention and particularly according to embodiment 71 above, arechemical compounds, containing less than 35, preferably less than 30,more preferably less than 25 and most preferably less than 20 or evenless than 15 or less than 10 carbon atoms and/or having a molecularweight of less than 400, preferably less than 300 and most preferablyless than 200 g/mol or less than 170 g/mol and/or having no significantPPAR gamma agonistic activity. Compositions containing these Nrf2activators are preferred.

72. PPAR gamma agonist for use in combination with an Nrf2 activator andcompositions according to any of the foregoing embodiments,characterized in that the nrf2 activator is selected from2-naphthoquinone, cynnamic aldehyde, caffeic acid and its esters,curcumin, reservatrol, artesunate, tert-butylhydroquinone, vitamins K1,K2 and K3 and the respective quinone or hydroquinone forms of theaforementioned quinone and hydroquinone derivatives, fumaric acidesters, i.e. fumaric acid mono- and/or diester which is preferablyselected from the group of monoalkyl hydrogen fumarate and dialkylfumarate, such as monomethyl hydrogen fumarate, dimethyl fumarate,monoethyl hydrogen fumarate, and diethyl fumarate, isothiocyanate suchas sulforaphane, 1,2-dithiole-3-thione such as oltipraz,3,5-di-tert-butyl-4-hydroxytoluene, 3-hydroxycoumarin, 4-hydroxynonenal,4-oxononenal, malondialdehyde, (E)-2-hexenal, capsaicin, allicin,allylisothiocyanate, 6-methylthiohexyl isothiocyanate,7-methylthioheptyl isothiocyanate, sulforaphane, 8-methylthiooctylisothiocyanate, 8-iso prostaglandin A2, alkyl pyruvate, such as methyland ethyl pyruvate, diethyl or dimethyl oxaloproprionate,2-acetamidoacrylate, and methyl or ethyl-2-acetamidoacrylate, and apharmacologically active stereoisomer or derivative of theaforementioned agents.

73. PPAR gamma agonist for use in combination with an Nrf2 activator andcompositions according to any the foregoing embodiments, characterizedin that the nrf2 activator is selected from monomethyl hydrogenfumarate, dimethyl fumarate, oltipraz, 1,2-naphthoquinone,tert-butylhydroquinone, methyl or ethyl pyruvate,3,5-di-tert-butyl-4-hydroxytoluene, diethyl and dimethyloxaloproprionate.

74. Kit of parts comprising a) a PPAR gamma agonist other thanpioglitazone and b) an Nrf2 activator selected from the group ofmonoalkyl hydrogen fumarate, dialkyl fumarate and bardoxolone alkyl andoptionally c) instructions for a dosing regime.

75. Kit of parts comprising a) a PPAR gamma agonist having nosignificant activating effect on Nrf2, b) an Nrf2 activator selectedfrom the group of monoalkyl hydrogen fumarate, dialkyl fumarate andbardoxolone and optionally c) instructions for a dosing regime.

76. Kit of parts comprising a) a PPAR gamma agonist having nosignificant activating effect on Nrf2, b) an Nrf2 activator having nosignificant PPAR gamma agonistic effect and optionally c) instructionsfor a dosing regime.

77. Kit of parts comprising a) a PPAR gamma agonist having nosignificant activating effect on Nrf2, b) an Nrf2 activator selectedchemical compounds belonging to the group of Michael reaction acceptors,phenols, diphenols, chalcones, isothiocyanates, thiocarbamates,quinones, naphtoquinones and 1,2 dithiole-3-thiones, wherein one ormore, preferably 1, 2, 3, 4, 5, 6 or 7 H-atoms may be substituted bylinear or branched alkyl and perfluoroalkyl, such as methyl, ethyl,trifluoromethyl, halogen such as Br, Cl F or I, hydroxy, alkoxy andperfluoroalkoxy, such as methoxy, ethoxy, trifluoromethoxy, cyano andnitro, which chemical compounds have not more than one or two 5- or6-membered carbocyclic rings or 5- or 6-membered heterocyclic ringshaving 1, 2 or 3 N—, O or S-atoms as ring atoms which rings may be fusedto each other or preferably no or only one carbocyclic or heterocyclicring and optionally c) instructions for a dosing regime.

78. Composition comprising a) a PPAR gamma agonist, preferably otherthan pioglitazone and b) an Nrf2 activator selected from the group ofmonoalkyl hydrogen fumarate, dialkyl fumarate and bardoxolone alkyl.

79. Composition comprising a) a PPAR gamma agonist having no significantactivating effect on Nrf2, b) an Nrf2 activator selected from the groupof monoalkyl hydrogen fumarate, dialkyl fumarate and bardoxolone.

80. Composition comprising a) a PPAR gamma agonist having no significantactivating effect on Nrf2, b) an Nrf2 activator having no significantPPAR gamma agonistic effect.

81. Composition comprising a) a PPAR gamma agonist having no significantactivating effect on Nrf2, b) an Nrf2 activator selected chemicalcompounds belonging to the group of Michael reaction acceptors, phenols,diphenols, chalcones, isothiocyanates, thiocarbamates, quinones,naphtoquinones and 1,2 dithiole-3-thiones, wherein one or more,preferably 1, 2, 3, 4, 5, 6 or 7 H-atoms may be substituted by linear orbranched alkyl and perfluoroalkyl, such as methyl, ethyl,trifluoromethyl, halogen such as Br, Cl F or I, hydroxy, alkoxy andperfluoroalkoxy, such as methoxy, ethoxy, trifluoromethoxy, cyano andnitro, which chemical compounds have not more than one or two 5- or6-membered carbocyclic rings or 5- or 6-membered heterocyclic ringshaving 1, 2 or 3 N—, O or S-atoms as ring atoms which rings may be fusedto each other or preferably no or only one carbocyclic or heterocyclicring.

82. Method of treating or preventing cancer, preferably heamatologicalcancer such as leukemia such as acute myeloid leukaemia (AML),comprising administration of a ppar gamma agonist and an Nrf2 activatorto a patient in need thereof, wherein said Nrf2 activator is capable ofprovoking or inducing a stimulated and/or increased nucleartranslocation of Nrf2 protein and is

a) selected from the group of Michael reaction acceptors, phenols,diphenols, chalcones, isothiocyanates, thiocarbamates, quinones,naphtoquinones and 1,2 dithiole-3-thiones; and

b) contains less than 35 carbon atoms; and/or

c) has a molecular weight of less than 600 g/mol; and/or

d) contains no or not more than one or two fused or monocyclic 5- or6-membered carbocyclic or heterocyclic rings, having 1, 2 or 3 ringatoms selected from N, O or S.

In one embodiment of the foregoing method, the Nrf2 activator ispreferably other than arsenic trioxide. Preferably, the Nrf2 activatoris dimethyl fumarate, monomethyl hydrogen fumarate or bardoloxolonemethyl.

83. Method of treating or preventing diabetes such as type II diabetesand its complications, such as arthritis, chronic kidney disease andsyndrome x, comprising administration of a ppar gamma agonist and anNrf2 activator to a patient in need thereof, wherein said Nrf2 activatoris capable of provoking or inducing a stimulated and/or increasednuclear translocation of Nrf2 protein and is

a) selected from the group of Michael reaction acceptors, phenols,diphenols, chalcones, isothiocyanates, thiocarbamates, quinones,naphtoquinones and 1,2 dithiole-3-thiones; and

b) contains less than 35 carbon atoms; and/or

c) has a molecular weight of less than 600 g/mol; and/or

d) contains no or not more than one or two fused or monocyclic 5- or6-membered carbocyclic or heterocyclic rings, having 1, 2 or 3 ringatoms selected from N, O or S.

In one embodiment of the foregoing method, the Nrf2 activator ispreferably other than bardoxolone methyl and/or a corticosteroide.Preferably, the Nrf2 activator is dimethyl fumarate or monomethylhydrogen fumarate.

84. Method of treating or preventing cardiovascular diseases, comprisingadministration of a ppar gamma agonist and an Nrf2 activator to apatient in need thereof, wherein said Nrf2 activator is capable ofprovoking or inducing a stimulated and/or increased nucleartranslocation of Nrf2 protein and is

a) selected from the group of Michael reaction acceptors, phenols,diphenols, chalcones, isothiocyanates, thiocarbamates, quinones,naphtoquinones and 1,2 dithiole-3-thiones; and

b) contains less than 35 carbon atoms; and/or

c) has a molecular weight of less than 600 g/mol; and/or

d) contains no or not more than one or two fused or monocyclic 5- or6-membered carbocyclic or heterocyclic rings, having 1, 2 or 3 ringatoms selected from N, O or S.

85. Method of treating or preventing respiratory diseases, such asasthma, chronic obstructive pulmonary disorder and fibrosis, comprisingadministration of a ppar gamma agonist and an Nrf2 activator to apatient in need thereof, wherein said Nrf2 activator is capable ofprovoking or inducing a stimulated and/or increased nucleartranslocation of Nrf2 protein and is

a) selected from the group of Michael reaction acceptors, phenols,diphenols, chalcones, isothiocyanates, thiocarbamates, quinones,naphtoquinones and 1,2 dithiole-3-thiones; and

b) contains less than 35 carbon atoms; and/or

c) has a molecular weight of less than 600 g/mol; and/or

d) contains no or not more than one or two fused or monocyclic 5- or6-membered carbocyclic or heterocyclic rings, having 1, 2 or 3 ringatoms selected from N, O or S.

In one embodiment of the foregoing method, the Nrf2 activator ispreferably other than a corticosteroide. Preferably, the Nrf2 activatoris dimethyl fumarate, monomethyl hydrogen fumarate or bardoloxolonemethyl.

86. Method of treating or preventing graft rejection and/or necrosis,comprising administration of a ppar gamma agonist and an Nrf2 activatorto a patient in need thereof, wherein said Nrf2 activator is capable ofprovoking or inducing a stimulated and/or increased nucleartranslocation of Nrf2 protein and is

a) selected from the group of Michael reaction acceptors, phenols,diphenols, chalcones, isothiocyanates, thiocarbamates, quinones,naphtoquinones and 1,2 dithiole-3-thiones; and

b) contains less than 35 carbon atoms; and/or

c) has a molecular weight of less than 600 g/mol; and/or

d) contains no or not more than one or two fused or monocyclic 5- or6-membered carbocyclic or heterocyclic rings, having 1, 2 or 3 ringatoms selected from N, O or S.

87. Method of treating or preventing psoriasis, comprisingadministration of a ppar agonist and an Nrf2 activator to a patient inneed thereof, wherein said Nrf2 activator is capable of provoking orinducing a stimulated and/or increased nuclear translocation of Nrf2protein and is

a) selected from the group of Michael reaction acceptors, phenols,diphenols, chalcones, isothiocyanates, thiocarbamates, quinones,naphtoquinones and 1,2 dithiole-3-thiones; and

b) contains less than 35 carbon atoms; and/or

c) has a molecular weight of less than 600 g/mol; and/or

d) contains no or not more than one or two fused or monocyclic 5- or6-membered carbocyclic or heterocyclic rings, having 1, 2 or 3 ringatoms selected from N, O or S.

In one embodiment of the foregoing method, no therapeutic amounts ofhydroxurea are co-administrated to the patient. In another embodiment ofthe foregoing method, no therapeutic amounts of monomethyl hydrogenfumarate are co-administrated to the patient. In another embodiment ofthe foregoing method, no therapeutic amounts of dimethyl fumarate areco-administrated to the patient. In another embodiment of the foregoingmethod, the Nrf2 activator is bardoloxolone methyl. In anotherembodiment of the foregoing method, the ppar agonist is other thanpioglitazone, such as rosiglitazone.

88. Method of treating or preventing autoimmune and/or inflammatorydiseases other than psoriasis, comprising administration of a pparagonist and dialkyl fumarate and/or monoalkyl hydrogen fumarate to apatient in need thereof.

89. Method of treating or preventing autoimmune and/or inflammatorydiseases other than chronic kidney disease, comprising administration ofa ppar agonist and bardoxolone methyl to a patient in need thereof

90. Method of treating or preventing cardiovascular diseases,respiratory disorders, graft rejection, cancer and diabetes and itscomplications, comprising administration of a ppar agonist and dimethylfumarate and/or monomethyl hydrogen fumarate to a patient in needthereof

91. Method of treating or preventing autoimmune/inflammatory andcardiovascular diseases, respiratory disorders, graft rejection, cancerand diabetes and its complications, comprising administration of a pparagonist other than pioglitazone, and dimethyl fumarate and/or monomethylhydrogen fumarate to a patient in need thereof.

92. PPAR gamma agonist for use in combination with an Nrf2 activator inthe treatment of an autoimmune and/or inflammatory disease.

93. PPAR gamma agonist for use in combination with an Nrf2 activatoraccording to embodiment 92, characterized in that the Nrf2 activator isdimethyl fumarate.

94. PPAR gamma agonist for use in combination with an Nrf2 activatoraccording to claim 92, characterized in that the Nrf2 activator isbardoxolone methyl.

95. PPAR gamma agonist for use in combination with an Nrf2 activatoraccording to one of the foregoing embodiments, characterized in that thePPAR gamma agonist is pioglitazone.

96. PPAR gamma agonist for use in combination with an Nrf2 activatoraccording to one of the foregoing embodiments, characterized in that thePPAR gamma agonist is selected from the group of rosiglitazone,troglitazone and ciglitazone.

97. PPAR gamma agonist for use in combination with an Nrf2 activatoraccording to one of the foregoing embodiments, characterized in that theautoimmune and/or inflammatory disease is psoriasis.

98. PPAR gamma agonist for use in combination with an Nrf2 activatoraccording to one of the foregoing embodiments, characterized in that theautoimmune and/or inflammatory disease is multiple sclerosis.

99. PPAR gamma agonist for use in combination with an Nrf2 activatoraccording to one of the foregoing embodiments, characterized in that theautoimmune and/or inflammatory disease is colitis ulcerosa.

100. PPAR gamma agonist for use in combination with an Nrf2 activatoraccording to one of the foregoing embodiments, characterized in that theautoimmune and/or inflammatory disease is Crohn's disease.

101. PPAR gamma agonist for use in combination with an Nrf2 activatoraccording to one of the foregoing embodiments, characterized in that theautoimmune and/or inflammatory disease is allopecia greata orcicatricial alopecia.

102. PPAR gamma agonist for use in combination with an Nrf2 activatoraccording to one of the foregoing embodiments, characterized in that theautoimmune and/or inflammatory disease is diabetic nephrophathy.

103. PPAR gamma agonist for use in combination with an Nrf2 activatoraccording to one of the foregoing embodiments, characterized in that theautoimmune and/or inflammatory disease is myasthenia gravis.

104. A pharmaceutical composition comprising pioglitazone, dimethylfumarate and optionally one or more excipients.

105. A pharmaceutical composition comprising dimethyl fumarate and aPPAR gamma agonist selected from rosiglitazone, troglitazone andciglitazone, and optionally one or more excipients.

106. A pharmaceutical composition comprising bardoxolone methyl and aPPAR gamma agonist selected from pioglitazone, rosiglitazone,troglitazone and ciglitazone, and optionally one or more excipients.

107. Method of treating or preventing neurodegenerative diseases,comprising administration of a PPAR gamma agonist selected from thegroup of glitazones and a fumaric acid monoalkyl and/or dialkyl ester toa patient in need thereof.

108. Method according to embodiment 107, wherein the fumaric aciddialkyl ester is selected from dimethyl fumarate and diethyl fumarateand the fumaric acid monoalkyl ester is selected from monomethylhydrogen fumarate and monoethyl hydrogen fumarate.

109. Method according to embodiment 107 or 108, wherein the PPAR gammaagonist glitazone is selected from pioglitazone and rosiglitazone.

110. Method according to embodiment 107, 108 or 109, wherein theneurodegenerative disease is multiple sclerosis.

111. A pharmaceutical composition comprising a ppar gamma agonistselected from the group of glitazones and a fumaric acid monoalkyland/or dialkyl ester and optionally one or more excipients.

112. A pharmaceutical composition according to embodiment 111, whereinthe fumaric acid dialkyl ester is selected from dimethyl fumarate anddiethyl fumarate and the fumaric acid monoalkyl ester is selected frommonomethyl hydrogen fumarate and monoethyl hydrogen fumarate.

113. A pharmaceutical composition according to embodiment 111 or 112,wherein the PPAR gamma agonist glitazone is selected from pioglitazoneand rosiglitazone.

114. Method of treating or preventing neurodegenerative diseases,comprising administration of a pharmaceutical composition according toembodiments 111, 112 or 113 to a patient in need thereof.

115. Method according to embodiment 114, wherein the neurodegenerativedisease is multiple sclerosis.

116. A solid oral dosage form comprising a ppar gamma agonist selectedfrom the group of glitazones and a fumaric acid monoalkyl and/or dialkylester and optionally one or more excipients.

117. A solid oral dosage form according to embodiment 116, wherein thefumaric acid dialkyl ester is selected from dimethyl fumarate anddiethyl fumarate and the fumaric acid monoalkyl ester is selected frommonomethyl hydrogen fumarate and monoethyl hydrogen fumarate.

118. A solid oral dosage form according to embodiment 116 or 117,wherein the PPAR gamma agonist glitazone is selected from pioglitazoneand rosiglitazone.

119. Method of treating or preventing neurodegenerative diseases,comprising oral administration of a solid oral dosage form according toembodiments 116, 117 or 118 to a patient in need thereof

120. Method according to embodiment 119, wherein the neurodegenerativedisease is multiple sclerosis.

121. Kit of parts comprising a) a ppar gamma agonist selected from thegroup of glitazones and b) a fumaric acid monoalkyl and/or dialkyl esterand optionally c) instructions for a dosage regime.

122. Kit of parts according to embodiment 121, wherein the fumaric aciddialkyl ester is selected from dimethyl fumarate and diethyl fumarateand the fumaric acid monoalkyl ester is selected from monomethylhydrogen fumarate and monoethyl hydrogen fumarate.

123. Kit of parts according to embodiment 121 or 122, wherein the PPARgamma agonist glitazone is selected from pioglitazone and rosiglitazone.

Preferably, the PPAR agonist and the Nrf2 activator used in the presentinvention do not belong to the same chemical class of compounds, i.e.the Nrf2 activator preferably belongs to a different class of compoundsas the PPAR agonist.

Solid oral dosage forms comprising the inventive combinations for use intreatment of inflammatory and/or autoimmune diseases are preferred.

Preferred is also a composition comprising dimethyl fumarate, monomethylfumarate, optionally in form of its zinc, magnesium and/or calcium saltsand a PPAR agonist. The use of this composition in the treatment ofpsoriasis is particularly preferred.

Preferred is also a PPAR gamma agonist for use in combination with anNrf2 activator in the treatment of an autoimmune and/or inflammatorydisease, according to any of the foregoing embodiments, characterized inthat the treatment does not comprise or excludes the administration ofhydroxyurea (hydroycarbamid).

Pioglitazone and rosiglitazone tablets are commercially available andcan be used as such for the combination therapy according to theinvention.

In one embodiment, preferred tablets are film-coated tablets containingrosiglitazone maleate equivalent to rosiglitazone, 2 mg, 4 mg, or 8 mg,for oral administration, with the following inactive ingredients:Hypromellose 2910, lactose monohydrate, magnesium stearate,microcrystalline cellulose, polyethylene glycol 3000, sodium starchglycolate, titanium dioxide, triacetin, and 1 or more of the following:Synthetic red and yellow iron oxides and talc.

In one embodiment, preferred tablet for oral administration contain 15mg, 30 mg, or 45 mg of pioglitazone (as the base) formulated with thefollowing excipients: lactose monohydrate NF, hydroxypropylcellulose NF,carboxymethylcellulose calcium NF, and magnesium stearate NF.

Other formulations can be obtained in analogy to US6355676, US7976853and 6403121.

Throughout the specification, the term “no significant PPAR gammaagonistic activity” or “no significant PPAR gamma agonistic effect”means that at the therapeutically useful concentration of the Nrf2activator, no therapeutically useful PPAR gamma activation can beobtained or measured.

Throughout the specification, the term “no significant effect on Nrf2”or “no significantly activating effect on Nrf2” or “no significanteffect on Nrf2 activity” means that at the therapeutically usefulconcentration of the PPAR gamma agonist, no therapeutically useful Nrf2activation can be obtained or measured.

The term monoalkyl fumarate and monoalkyl hydrogen fumarate are usedsynonymously, such as monomethyl fumarate and monomethyl hydrogenfumarate.

EXAMPLES Example 1 Preparation of Enteric-Coated Micro-Tablets inCapsules Containing 120.0 mg of Dimethyl Fumarate

Following U.S. Pat. No. 7,320,999, 12.000 kg of dimethyl fumarate arecrushed, mixed and homogenized by means of a sieve 800. Then anexcipient mixture with the following composition is prepared: 17.50 kgof starch derivative (STA-RX® 1500), 0.30 kg of microcrystallinecellulose (Avicel® PH 101), 0.75 kg of PVP (Kollidon® 120), 4.00 kg ofPrimogel®, 0.25 kg of colloidal silicic acid (Aerosil®). Dimethylfumarate is added to the entire powder mixture, mixed, homogenized bymeans of a sieve 200, processed in the usual manner with a 2% aqueoussolution of polyvidon pyrrolidone (Kollidon® K25) to obtain a bindergranulate and then mixed in the dry state with the outer phase. Saidouter phase consists of 0.50 kg of Mg stearate and 1.50 kg of talcum.

The powder mixture is compressed in the usual manner into 10 mg-microtablet cores.

To achieve resistance to gastric acid a solution of 2.250 kg of hydroxypropyl methyl cellulose phthalate (HPMCP, Pharmacoat® HP 50) isdissolved in portions in a mixture of the following solvents: 13.00 L ofacetone, 13.50 L of ethanol (94 wt.-%, denatured with 2% of ketone) and1.50 L of demineralised water. As a plasticiser, castor oil (0.240 kg)is added to the finished solution, which is applied in portions onto themicro tablet cores in the customary manner.

After drying is completed, a suspension of the following composition isapplied as a film coat in the same apparatus: 0.340 kg of talcum, 0.400kg of titanium(VI) oxide Cronus RN 56, 0.324 kg of coloured lacquerL-Rot-lack 86837, 4.800 kg of Eudragit E 12.5% and 0.120 kg ofpolyethylene glycol 6000, pH 11 XI in a solvent mixture of the followingcomposition: 8.170 kg of 2-propanol, 0.200 kg of demineralised water and0.600 kg of glycerine triacetate (Triacetin). This procedure resulted inenteric-coated micro-tablets.

Subsequently, the enteric-coated micro-tablets are filled into hardgelatine capsules and are sealed for use according to the invention.

Micro pellets can be obtained similarly according to US7320999.

Example 2 Preparation of Tablets Containing Pioglitazone and DimethylFumarate in Separate Tablet Layers

According to U.S. Pat. No. 807,113, a mixture of pioglitazonehydrochloride (99.2 g), croscarmellose sodium (13.2 g) and lactose(184.9 g) is granulated by spraying thereon 136.2 g of an aqueoussolution of hydroxypropylcellulose (6.81 g), in a fluid bed granulator(manufactured by Powrex Corp., Model: LAB-1). The resulting granulatedpowder is then granulated by spraying a suspension obtained bydispersing lactose (36 g) in 148.6 g of an aqueous solution ofhydroxypropylcellulose (7.59 g) thereon in a fluid bed granulator(manufactured by Powrex Corp., Model: LAB-1) to obtain pioglitazonehydrochloride-containing granulated powder coated with lactose. To apart (23.18 g) of the granulated powder thus obtained, croscarmellosesodium (0.728 g) and magnesium stearate (0.096 g) are added and mixed toobtain pioglitazone hydrochloride-containing mixed powder. Thepioglitazone hydrochloride-containing mixed powder is compressed in theform of laminate with a powder obtained according to example 1,containing dimethyl fumarate, a starch derivative (STA-RX® 1500),microcrystalline cellulose (Avicel® PH 101), PVP (Kollidon® 120),Primogel®, and colloidal silicic acid (Aerosil®).

Example 3

According to US7976853, hydroxypropyl cellulose (26.4 g, Grade SSL,Nippon Soda Co., Ltd.) (viscosity of 5% aqueous solution at 20° C.: 8mPa·s), polyethylene glycol 6000 (1.32 g), titanium oxide (2.64 g) andpioglitazone hydrochloride (16.5 g) are dispersed in water (297 g) togive a coating solution. The enteric coated micro-tablets obtained inexample 1 are fed in a film coating equipment (Hicoater-Mini, FreundIndustrial Co. Ltd.) and coated with the aforementioned coating solutionto give a coated preparation. Subsequently, these enteric-coatedmicro-tablets, which are coated with pioglitazone hydrochloride, arefilled into hard gelatine capsules and are sealed for use according tothe present invention.

Alternatively, according to example 1, an enteric-coated tabletcontaining the desired amount of dimethyl fumarate can be obtained,followed by a coating with a pioglitazone formulation as describedabove. The tablets can be used as such for the combination treatmentaccording to the invention.

Example 4

A mixture of pioglitazone hydrochloride (99.2 g), croscarmellose sodium(13.2 g) and lactose (184.9 g) which is granulated by spraying thereon136.2 g of an aqueous solution of hydroxypropylcellulose (6.81 g), in afluid bed granulator (manufactured by Powrex Corp., Model: LAB-1). Theresulting granulated powder is then granulated by spraying a suspensionobtained by dispersing lactose (36 g) in 148.6 g of an aqueous solutionof hydroxypropylcellulose (7.59 g) thereon in a fluid bed granulator(manufactured by Powrex Corp., Model: LAB-1) to obtain pioglitazonehydrochloride-containing granulated powder coated with lactose. Adesired amount of the granulated powder thus obtained, is filled in acapsules containing dimethyl fumarate enteric-coated micro tabletsobtained according to example 1, which are thereafter sealed.

Example 5

A capsule is filled a dispersion of 20 mg of amorphous bardoxolonemethyl in methacrylic acid copolymer Type C, USP in a 4/6 weight ratioof bardoxolone methyl to methacrylic acid copolymer Type C, USP havingthe following composition is prepared according to US2012/022156:

Amorphous bardoxolone methyl as 40% dispersion: 11.36%

SMCC (90LM, silicified microcrystalline cellusose, as listed in the FDAInactive Ingredients Guide): 36.36%

lactose monohydrate: 40.91%

hydroxypropyl methylcellulose: 6.82%

colloidal silicon dioxide: 0.91%

magnesium Stearate: 0.91%

sodium lauryl sulphate: 2.73%.

In addition, the capsule is filled with an equivalent of 45 mg ofpioglitazone in form of its hydrochloride as a granulated powder coatedwith lactose obtained according to the first part of example 4. Thecapsule is thereafter sealed for use.

Alternatively, the bardoxolone methyl containing mixture and thepioglitazone containing mixture can be compressed into a tablet,preferably a layered tablet, wherein the formulations are arranged in alaminar manner. In one embodiment, an enteric coat is applied to thetablet.

General Experimental Protocols

Treatment in the following animal models consists of, or animals aretreated with, dimethyl fumarate and pioglitazone which are dissolved ordispersed in 0.5% methocellulose/0.1% Tween80 in distilled water andadministered by oral gavage twice daily. Treatment groups are generallyas follows: vehicle alone, dimethyl fumarate alone, pioglitazone aloneor the combination of dimethyl fumarate and pioglitazone. Thecombination according to the invention results in an improved responseto treatment over the vehicle and the respective agents alone.

The effect of the combinations according to the present invention in thetreatment of cancer and preferably hematologic cancers such as CLL andAML can be found according to Blood. 2006 Nov. 15; 108(10):3530-7 andCancer Res Jun. 15, 2010 70; 4949.

EAE Animal Model for Assessing Therapeutic Effect of the Combination ofa PPAR Gamma Agonist and an Nrf2 Activator for Treating MultipleSclerosis

Animals and EAE Induction Female C57BL/6 mice, 8-10 weeks old (HarlanLaboratories, Livermore, Calif.), are immunized subcutaneously in theflanks and mid-scapular region with 200 μg of myelin oligodendrocyteglycoprotein peptide (MOG3S-Ss) (synthesized by Invitrogen) emulsified(1:1 volume ratio) with complete Freund's adjuvant (CFA) (containing 4mg/nL Mycobacterium tuberculosis). Emulsion is prepared by thesyringe-extrusion method with two glass Luer-Lock syringes connected bya 3-way stopcock. Mice are also given an intraperitoneal injection of200 ng pertussis toxin (List Biological Laboratories, Inc, Campbell,Calif.) on the day of immunization and on day two post immunization.Mice are weighed and examined daily for clinical signs of experimentalautoimmune encephalomyelitis (EAE). Food and water is provided adlibitum and once animals start to show disease, food is provided on thecage bottom.

Clinical Evaluation

Mice are scored daily beginning on day 7 post immunization. The clinicalscoring scale is as follows (Miller and Karplus, Current Protocols inImmunology 2007, 15.1.1-15.1.18): 0=normal; 1=limp tail or hind limbweakness (defined by foot slips between bars of cage top while walking);2=limp tail and hind limb weakness; 3=partial hind limb paralysis(defined as no weight bearing on hind limbs but can still move one orboth hind limbs to some extent); 4=complete hind limb paralysis;5=moribund state (includes forelimb paralysis) or death.

Use of an Animal Model to Assess Effect in Treating Psoriasis

The severe, combined immunodeficient (SCID) mouse model can be used toevaluate the efficacy of compounds for treating psoriasis in humans(Boehncke, Ernst Schering Res Found Workshop 2005, 50, 213-34; andBhagavathula et al, J Pharmacol Expt 7 Therapeutics 2008, 324(3),938-947).

SCID mice are used as tissue recipients. One biopsy for each normal orpsoriatic volunteer is transplanted onto the dorsal surface of arecipient mouse. Treatment is initiated 1 to 2 weeks aftertransplantation. Animals with the human skin transplants are dividedinto treatment groups. Animals are treated twice daily for 14 days. Atthe end of treatment, animals are photographed and then euthanized. Thetransplanted human tissue along with the surrounding mouse skin issurgically removed and fixed in 10% formalin and samples obtained formicroscopy. Epidermal thickness is measured. Tissue sections are stainedwith an antibody to the proliferation-associated antigen Ki-67 and withan anti-human CD3+ monoclonal antibody to detect human T lymphocytes inthe transplanted tissue. Sections are also probed with antibodies toc-myc and β-catenin. A positive response to treatment is reflected by areduction in the average epiderma thickness of the psoriatic skintransplants. A positive response is also associated with reducedexpression of Ki-67 in keratinocytes.

Animal Model for Assessing Therapeutic Effect of the Combination of aPPAR Gamma Agonist and an Nrf2 Activator for Treating Multiple Sclerosis

Experiments are conducted on female mice aged 4-6 weeks belong to theC57BL/6 strain weighing 17-20 g. Experimental autoimmuneencephalomyelitis (EAE) is actively induced using >95% pure syntheticmyelin oligodendrocyte glycoprotein peptide 35-55 (MOG35-55,MEVGWYRSPFSRVVHLYRNGK, SEQ ID NO: 1). Each mouse is anesthetized andreceives 200 μg of MOG peptide and 15 μg of Saponin extract from Quilijabark emulsified in 100 μL of phosphate-buffered saline. A 25 μL volumeis injected subcutaneously over four flank areas. Mice are alsointraperitoneally injected with 200 ng of pertussis toxin in 200 μL ofPBS. A second, identical injection of pertussis toxin is given after 48h.

Daily treatment extends from day 26 to day 36 post-immunization.Clinical scores are obtained daily from day 0 post-immunization untilday 60. Clinical signs are scored using the following protocol: 0, nodetectable signs; 0.5, distal tail limpness, hunched appearance andquiet demeanor; 1, completely limp tail; 1.5, limp tail and hindlimbweakness (unsteady gait and poor grip with hindlimbs); 2, unilateralpartial hindlimb paralysis; 2.5, bilateral hindlimb paralysis; 3,complete bilateral hindlimb paralysis; 3.5, complete hindlimb paralysisand unilateral forelimb paralysis; 4, total paralysis of hindlimbs andforelimbs (Eugster et al., Eur J Immunol 2001, 31, 2302-2312).

Inflammation and demyelination are assessed by histology on sectionsfrom the CNS of EAE mice. Mice are sacrificed after 30 or 60 days andwhole spinal cords are removed and placed in 0.32 M sucrose solution at40° C. overnight. Tissues are prepared and sectioned. Luxol fast bluestain is used to observe areas of demyelination. Haematoxylin and eosinstaining is used to highlight areas of inflammation by darkly stainingthe nuclei of mononuclear cells. Immune cells stained with H&E arecounted in a blinded manner under a light microscope. Sections areseparated into gray and white matter and each sector is counted manuallybefore being combined to give a total for the section. T cells areimmunolabeled with anti-CD3+ monoclonal antibody. After washing,sections are incubated with goat anti-rat HRP secondary antibody.Sections are then washed and counterstained with methyl green.Splenocytes isolated from mice at 30 and 60 days post-immunization aretreated with lysis buffer to remove red blood cells. Cells are thenresuspended in PBS and counted. Cells at a density of about 3×106cells/mL are incubated overnight with 20 μg/mL of MOG peptide.Supernatants from stimulated cells are assayed for IFN-γ protein levelsusing an appropriate mouse IFN-γ immunoassay system.

Use of an Animal Model to Assess Effect in Treating Inflammatory BowelDisease

Animal models of inflammatory bowel disease are described by Jurjus etal, J Pharmaocol Toxicol Methods 2004, 50, 81-92; Villegas et al, Int'lImmunopharmacol 2003, 3, 1731-1741; and Murakami et al, BiochemicalPharmacol 2003, 66, 1253-1261. For example, the following protocol canbe used to assess the effect of the combination according to the presentinvention for treating inflammatory bowel disease, morbus Crohn andcolitis.

Female ICR mice are used. Mice are divided into treatment groups. Groupsare given either water (control), 5% DSS in tap water is given at thebeginning of the experiment to induce colitis, or treatment is given.After administering the treatment for 1 week, 5% DSS in tap water isalso administered to the groups receiving treatment for 1 week. At theend of the experiment, all mice are killed and the large intestine isremoved. Colonic mucosa samples are obtained and homogenized.Proinflammatory mediators (e.g., IL-1α, IL-1β, TNF-α, PGE2, and PGF2α)and protein concentrations are quantified. Each excised large intestineis histologically examined and the damage to the colon scored.

Clinical Trial for Assessing Effect in Treating Asthma

Adult subjects (nonsmokers) with stable mild-to-moderate asthma areenrolled (see, e.g., Van Schoor and Pauwels, Eur Respir J 2002, 19,997-1002). A randomized, double-blind, placebo-controlled, two-periodcrossover design is used. Placebo, dimethyl fumarate alone, pioglitazonealone and a combination of dimethyl fumarate and pioglitazone isadministered orally in different arms. The combination according to theinvention results in an improved response to treatment over the vehicleand the agents alone.

Use of an Animal Model to Assess Effect in Treating Chronic ObstructivePulmonary

Disease animal model using mice chronically exposed to cigarette smokecan be used for assessing efficacy in treating emphysema (see, e.g.,Martorana et al., Am J Respir Crit. Care Med 2005, 172, 848-835; andCavarra et al., Am J Respir Crit. Care Med 2001, 164, 886-890). Six-weekold C57B1/6J male mice are used. In the acute study, the mice areexposed either to room air or to the smoke of five cigarettes for 20minutes. In the chronic study, the mice are exposed to either room airor to the smoke of three cigarettes/day for 5 days/week for 7 months.

In the acute study, mice are divided into three groups. These groups arethen divided into four subgroups of 10 mice each as follows: (1) notreatment/air-exposed; (2) no treatment/smoke-exposed; (3) thecombination of dimethyl fumarate and pioglitazone plus smoke-exposed;and (4) pioglitazone plus smoke-exposed; and (5) dimethyl fumarate plussmoke-exposed. In the first group, trolox equivalent antioxidantcapacity is assessed at the end of the exposure in bronchoalveolarlavage fluid. In the second group, cytokines and chemokines aredetermined in bronchoalveolar lavage fluid using a commercial cytokinepanel at 4 hours; and in the third group bronchoalveolar lavage fluidcell count is assessed at 24 hours.

Animal Models for Assessing Therapeutic Effect of the Combination of aPPAR Gamma Agonist and an Nrf2 Activator for Treating Parkinson'sDisease MPTP Induced Neurotoxicity

MPTP, or 1-methyl-4-phenyl-1,2,3,6-tetrahydropyridine is a neurotoxinthat produces a Parkinsonian syndrome in both man and experimentalanimals. Studies of the mechanism of MPTP neurotoxicity show that itinvolves the generation of a major metabolite, MPP+, formed by theactivity of monoamine oxidase on MPTP. Inhibitors of monoamine oxidaseblock the neurotoxicity of MPTP in both mice and primates. Thespecificity of the neurotoxic effects of MPP+ for dopaminergic neuronsappears to be due to the uptake of MPP+ by the synaptic dopaminetransporter. Blockers of this transporter prevent MPP+ neurotoxicity.MPP+ has been shown to be a relatively specific inhibitor ofmitochondrial complex I activity, binding to complex I at the retenonebinding site and impairing oxidative phosphorylation. In vivo studieshave shown that MPTP can deplete striatal ATP concentrations in mice. Ithas been demonstrated that MPP+ administered intrastriatally to ratsproduces significant depletion of ATP as well as increased lactateconcentration confined to the striatum at the site of the injections.Compounds that enhance ATP production can protect against MPTP toxicityin mice.

Mice or rats are treated either with vehicle alone, dimethyl fumaratealone pioglitazone alone or the combination of dimethyl fumarate andpioglitazone for three weeks before treatment with MPTP. MPTP isadministered at an appropriate dose, dosing interval, and mode ofadministration for 1 week before sacrifice. Control groups receiveeither normal saline or MPTP hydrochloride alone. Following sacrificethe two striate are rapidly dissected and placed in chilled 0.1 Mperchloric acid. Tissue is subsequently sonicated and aliquots analyzedfor protein content using a fluorometer assay. Dopamine,3,4-dihydroxyphenylacetic acid (DOPAC), and homovanillic acid (HVA) arealso quantified. Concentrations of dopamine and metabolites areexpressed as nmol/mg protein.

Haloperidol-Induced Hypolocomotion

The ability of a compound to reverse the behavioral depressant effectsof dopamine antagonists such as haloperidol, in rodents and isconsidered a valid method for screening drags with potentialantiparkinsonian effects (Mandhane, et al., Eur. J. Pharmacol 1997, 328,135-141). Hence, the ability of the treatment to blockhaloperidol-induced deficits in locomotor activity in mice can be usedto assess both in vivo and potential anti-Parkinsonian efficacy.

Mice used in the experiments are housed in a controlled environment andallowed to acclimatize before experimental use. One and one-half (1.5)hours before testing, mice are administered 0.2 mg/kg haloperidol, adose that reduces baseline locomotor activity by at least 50%. Treatmentis administered a suitably long prior to testing. The animals are thenplaced individually into clean, clear polycarbonate cages with a flatperforated lid.

Horizontal locomotor activity is determined by placing the cages withina frame containing a 3×6 array of photocells interfaced to a computer totabulate beam interrupts. Mice are left undisturbed to explore for 1 h,and the number of beam interruptions made during this period serves asan indicator of locomotor activity, which is compared with data forcontrol animals for statistically significant differences.

6-Hydroxydopamine Animal Model

The neurochemical deficits seen in Parkinson's disease can be reproducedby local injection of the dopaminergic neurotoxin, 6-hydroxydopamine(6-OHDA) into brain regions containing either the cell bodies or axonalfibers of the nigrostriatal neurons. By unilaterally lesioning thenigrostriatal pathway on only one-side of the brain, a behavioralasymmetry in movement inhibition is observed. Althoughunilaterally-lesioned animals are still mobile and capable of selfmaintenance, the remaining dopamine-sensitive neurons on the lesionedside become supersensitive to stimulation. This is demonstrated by theobservation that following systemic administration of dopamine agonists,such as apomorphine, animals show a pronounced rotation in a directioncontralateral to the side of lesioning. The ability of compounds toinduce contralateral rotations in 6-OHDA lesioned rats has been shown tobe a sensitive model to predict drug efficacy in the treatment ofParkinson's disease.

Male Sprague-Dawley rats are housed in a controlled environment andallowed to acclimatize before experimental use. Fifteen minutes prior tosurgery, animals are given an intraperitoneal injection of thenoradrenergic uptake inhibitor desipramine (25 mg/kg) to prevent damageto nondopamine neurons. Animals are then placed in an anesthetic chamberand anesthetized using a mixture of oxygen and isoflurane. Onceunconscious, the animals are transferred to a stereotaxic frame, whereanesthesia is maintained through a mask. The top of the head is shavedand sterilized using an iodine solution. Once dry, a 2 cm long incisionis made along the midline of the scalp and the skin retracted andclipped back to expose the skull. A small hole is then drilled throughthe skull above the injection site. In order to lesion the nigrostriatalpathway, the injection cannula is slowly lowered to position above theright medial forebrain bundle at −3.2 mm anterior posterior, -1.5 mmmedial lateral from the bregma, and to a depth of 7.2 mm below theduramater. Two minutes after lowering the cannula, 6-OHDA is infused ata rate of 0.5 μL/min over 4 min, to provide a final dose of 8 μg. Thecannula is left in place for an additional 5 min to facilitate diffusionbefore being slowly withdrawn. The skin is then sutured shut, the animalremoved from the sterereotaxic frame, and returned to its housing. Therats are allowed to recover from surgery for two weeks before behavioraltesting.

Rotational behavior is measured using a rotameter system havingstainless steel bowls (45 cm dia×15 cm high) enclosed in a transparentPlexiglas cover around the edge of the bowl and extending to a height of29 cm. To assess rotation, rats are placed in a cloth jacket attached toa spring tether connected to an optical rotameter positioned above thebowl, which assesses movement to the left or right either as partial(45°) or full (360°) rotations.

Treatment is given for a suitable period prior to testing. Animals aregiven a subcutaneous injection of a subthreshold dose of apomorphine,and are then placed in the harness. The number of rotations are recordedfor one hour. The total number of full contralateral rotations duringthe hour test period serves as an index of antiparkinsonian drugefficacy.

Animal Model for Assessing Therapeutic Effect for Treating Alzheimer'sDisease

Heterozygous transgenic mice expressing the Swedish AD mutant gene,hAPPK670N, M671L (Tg2576; Hsiao, Learning & Memory 2001, 8, 301-308) areused as an animal model of Alzheimer's disease. Animals are housed understandard conditions with a 12:12 light/dark cycle and food and wateravailable ad libitum. Beginning at 9 months of age, mice are dividedinto two groups. The groups of animals receive treatment over six weeks.

Behavioral testing is performed at each drug dose using the samesequence over two weeks in all experimental groups: (1) spatial reversallearning, (2) locomotion, (3) fear conditioning, and (4) shocksensitivity.

Acquisition of the spatial learning paradigm and reversal learning aretested during the first five days of test compound administration usinga water T-maze as described in Bardgett et al., Brain Res Bull 2003, 60,131-142. Mice are habituated to the water T-maze during days 1-3, andtask acquisition begins on day 4. On day 4, mice are trained to find theescape platform in one choice arm of the maze until 6 to 8 correctchoices are made on consecutive trails. The reversal learning phase isthen conducted on day 5. During the reversal learning phase, mice aretrained to find the escape platform in the choice arm opposite from thelocation of the escape platform on day 4. The same performance criteriaand inter-trial interval are used as during task acquisition.

Large ambulatory movements are assessed to determine that the results ofthe spatial reversal learning paradigm are not influenced by thecapacity for ambulation. After a rest period of two days, horizontalambulatory movements, excluding vertical and fine motor movements, areassessed in a chamber equipped with a grid of motion-sensitive detectorson day 8. The number of movements accompanied by simultaneous blockingand unblocking of a detector in the horizontal dimension are measuredduring a one-hour period.

The capacity of an animal for contextual and cued memory is tested usinga fear conditioning paradigm beginning on day 9. Testing takes place ina chamber that contains a piece of absorbent cotton soaked in anodor-emitting solution such as mint extract placed below the grid floor.A 5-min, 3 trial 80 db, 2800 Hz tone-foot shock sequence is administeredto train the animals on day 9. On day 10, memory for context is testedby returning each mouse to the chamber without exposure to the tone andfoot shock, and recording the presence or absence of freezing behaviorevery 10 seconds for 8 minutes. Freezing is defined as no movement, suchas ambulation, sniffing or stereotypy, other than respiration.

On day 11, the response of the animal to an alternate context and to theauditory cue is tested. Coconut extract is placed in a cup and the 80 dBtone is presented, but no foot shock is delivered. The presence orabsence of freezing in response to the alternate context is thendetermined during the first 2 minutes of the trial. The tone is thenpresented continuously for the remaining 8 minutes of the trial, and thepresence or absence of freezing in response to the tone is determined.

On day 12, the animals are tested to assess their sensitivity to theconditioning stimulus, i.e., foot shock. Following the last day ofbehavioral testing, animals are anesthetized and the brains removed,post-fixed overnight, and sections cut through the hippocampus. Thesections are stained to image β-amyloid plaques.

Data is analyzed using appropriate statistical methods.

Animal Model for Assessing Therapeutic Effect for Treating Huntington'sDisease

Neuroprotective Effects in a Transgenic Mouse Model of Huntington'sDisease Transgenic HD mice of the N171-82Q strain and non-transgeniclittermates are treated from 10 weeks of age. The mice are placed on arotating rod (“rotarod”). The length of time at which a mouse falls fromthe rotarod is recorded as a measure of motor coordination. The totaldistance traveled by a mouse is also recorded as a measure of overalllocomotion. Mice showing improved response to treatment with thecombination of dimethyl fumarate and pioglitazone remain on the rotarodfor a longer period of time and travel farther than mice administeredvehicle or either agent alone.

Malonate Model of Huntington's Disease

A series of reversible and irreversible inhibitors of enzymes involvedin energy generating pathways has been used to generate animal modelsfor neurodegenerative diseases such as Parkinson's and Huntington'sdiseases. In particular, inhibitors of succinate dehydrogenase, anenzyme that impacts cellular energy homeostasis, has been used togenerate a model for Huntington's disease.

In this malonate model for Huntington's disease, treatment isadministered at an appropriate dose, dosing interval, and route, to maleSprague-Dawley rats. Treatment is administered for two weeks prior tothe administration of malonate and then for an additional week prior tosacrifice. Malonate is dissolved in distilled deionized water and the pHadjusted to 7.4 with 0.1 M HCl. Intrastriatal injections of 1.5 μL of 3μmol malonate are made into the left striatum at the level of the Bregma2.4 mm lateral to the midline and 4.5 mm ventral to the dura. Animalsare sacrificed at 7 days by decapitation and the brains quickly removedand placed in ice cold 0.9% saline solution. Brains are sectioned at 2mm intervals in a brain mold. Slices are then placed posterior side downin 2% 2,3,5-tiphenyltetrazolium chloride. Slices are stained in the darkat room temperature for 30 min and then removed and placed in 4%paraformaldehyde pH 7.3. Lesions, noted by pale staining, are evaluatedon the posterior surface of each section. The measurements are validatedby comparison with measurements obtained on adjacent Nissl stainsections.

Animal Model for Assessing Therapeutic Effect for Treating AmyotrophicLateral Sclerosis

A murine model of SOD1 mutation-associated ALS has been developed inwhich mice express the human superoxide dismutase (SOD) mutationglycine—alanine at residue 93 (SOD1). These SOD1 mice exhibit a dominantgain of the adverse property of SOD, and develop motor neurondegeneration and dysfunction similar to that of human ALS. The SOD1transgenic mice show signs of posterior limb weakness at about 3 monthsof age and die at 4 months. Features common to human ALS includeastrocytosis, microgliosis, oxidative stress, increased levels ofcyclooxygenase/prostaglandin, and, as the disease progresses, profoundmotor neuron loss. Studies are performed on transgenic miceoverexpressing human Cu/Zn-SOD G93A mutations (B6S JL-TgN(SOD1-G93A) 1Gur) and non-transgenic B6/SJL mice and their wild litter mates. Miceare housed on a 12-hr day/light cycle and (beginning at 45 d of age)allowed ad libitum access to either test compound-supplemented chow, or,as a control, regular formula cold press chow processed into identicalpellets. Genotyping can be conducted at 21 days of age as described inGurney et al., Science 1994, 264(5166), 1772-1775. The SOD1 mice areseparated into groups and treatment is administered for a suitableperiod.

The mice are observed daily and weighed weekly. To assess health statusmice are weighed weekly and examined for changes inlacrimation/salivation, palpebral closure, ear twitch and pupillaryresponses, whisker orienting, postural and righting reflexes and overallbody condition score. A general pathological examination is conducted atthe time of sacrifice.

Motor coordination performance of the animals can be assessed by one ormore methods known to those skilled in the art. For example, motorcoordination can be assessed using a neurological scoring method. Inneurological scoring, the neurological score of each limb is monitoredand recorded according to a defined 4-point scale: 0—normal reflex onthe hind limbs (animal will splay its hind limbs when lifted by itstail); 1—abnormal reflex of hind limbs (lack of splaying of hind limbsweight animal is lifted by the tail); 2—abnormal reflex of limbs andevidence of paralysis; 3—lack of reflex and complete paralysis; and4—inability to right when placed on the side in 30 seconds or founddead. The primary end point is survival with secondary end points ofneurological score and body weight. Neurological score observations andbody weight are made and recorded five days per week. Data analysis isperformed using appropriate statistical methods. The rotarod testevaluates the ability of an animal to stay on a rotating dowel allowingevaluation of motor coordination and proprioceptive sensitivity. Theapparatus is a 3 cm diameter automated rod turning at, for example, 12rounds per min. The rotarod test measures how long the mouse canmaintain itself on the rod without falling. The test can be stoppedafter an arbitrary limit of 120 sec. Should the animal fall down before120 sec, the performance is recorded and two additional trials areperformed. The mean time of 3 trials is calculated. A motor deficit isindicated by a decrease of walking time.

In the grid test, mice are placed on a grid (length: 37 cm, width: 10.5cm, mesh size: 1×1 cm2) situated above a plane support. The number oftimes the mice put their paws through the grid is counted and serves asa measure for motor coordination. The hanging test evaluates the abilityof an animal to hang on a wire. The apparatus is a wire stretchedhorizontally 40 cm above a table. The animal is attached to the wire byits forepaws. The time needed by the animal to catch the string with itshind paws is recorded (60 sec max) during three consecutive trials.

Electrophysiological measurements (EMG) can also be used to assess motoractivity condition. Electromyographic recordings are performed using anelectromyography apparatus. During EMG monitoring mice are anesthetized.The measured parameters are the amplitude and the latency of thecompound muscle action potential (CMAP). CMAP is measured ingastrocnemius muscle after stimulation of the sciatic nerve. A referenceelectrode is inserted near the Achilles tendon and an active needleplaced at the base of the tail. A ground needle is inserted on the lowerback of the mice. The sciatic nerve is stimulated with a single 0.2 msecpulse at supramaximal intensity (12.9 mA). The amplitude (mV) and thelatency of the response (ms) are measured. The amplitude is indicativeof the number of active motor units, while distal latency reflects motornerve conduction velocity. The effect of the combinations according tothe present invention can also be evaluated using biomarker analysis. Toassess the regulation of protein biomarkers in SOD1 mice during theonset of motor impairment, samples of lumbar spinal cord (proteinextracts) are applied to ProteinChip Arrays with varying surfacechemical/biochemical properties and analyzed, for example, by surfaceenhanced laser desorption ionization time of flight mass spectrometry.Then, using integrated protein mass profile analysis methods, data isused to compare protein expression profiles of the various treatmentgroups. Analysis can be performed using appropriate statistical methods.

Animal Model for Assessing Therapeutic Effect in Myasthenia Gravis

Induction and clinical evaluation of EAMG according to InternationalImmunology, Vol. 10, No. 9, pp. 1359-1365

B6 and μMT mice are immunized s.c. along the shoulders and back with 20μg AChR with CFA in a total volume of 100 μl, and boosted twice atmonthly intervals with 20 μg of AChR in CFA s.c. at four sites on theshoulders and thighs. The mice are observed every other day in a blindedfashion for signs of muscle weakness characteristic of EAMG. Theclinical symptoms are graded between 0 and 3 (4): 0, no definite muscleweakness; 1, normal strength at rest but weak with chin on the floor andinability to raise the head after exercise consisting of 20 consecutivepaw grips; 2, as grade 1 and weakness at rest; and 3, moribund,dehydrated and paralyzed. Clinical EAMG is confirmed by injection ofneostigmine bromide and atropine sulfate. The mice are grouped andtreatment is administered for a suitable period before testing.

Animal Model for Assessing the Therapeutic Effect in Alopecia

The Dundee experimental bald rat (DEBR) and the C3H/HeJ mouse arewell-established animal models for alopecia greata and can be used forthe study of genetic aspects, pathogenesis and therapy of the disease.In C3H/HeJ mice alopecia greata can be experimentally induced bygrafting lesional skin from an affected mouse to a histocompatiblerecipient which offers the possibility to study the influence of variousfactors on the development of the disease. The mice are grouped andtreatment is administered for a suitable period before testing.

General Experimental Protocol

Treatment in the following animal models consists of, dimethyl fumaratedissolved or dispersed in 0.5% Hydroxypropyl methylcellulose (HPMC) K4M/0.25% Tween 20 and pioglitazone dissolved or dispersed in kleptose indistilled water. Treatments were administered by oral gavage once ortwice daily. Treatment groups were generally as follows: appropriatevehicles, dimethyl fumarate, pioglitazone or the combination of dimethylfumarate and pioglitazone. The combination according to the inventionresults in an improved response to treatment over the vehicle and therespective agents alone.

EAE Animal Model for Assessing Therapeutic Effect of the Combination ofthe PPAR Gamma Agonist and nrf2 Activator for Treating MultipleSclerosis

Female C57BL/6 mice are ordered (Janvier France or Charles River)between 7-8 weeks old and used between 9-11 weeks after anacclimatization period. Experimental autoimmune encephalomyelitis (EAE)is actively induced using >95% pure synthetic myelin oligodendrocyteglycoprotein peptide 35-55 (MOG35-55),Met-Glu-Val-Gly-Trp-Tyr-Arg-Ser-Pro-Phe-Ser-Arg-Val-Val-His-Leu-Tyr-Arg-Asn-Gly-Lys(SEQ ID NO: 1), Ref SC1272, NeoMPS). Each mouse is anesthetized andreceives a subcutaneous injection of 100 μl of a Complete FreundsAdjuvant (Ref 263810, Difco) emulsion containing 200 μg of MOG35-55 and250 μg of dried and killed M. tuberculosis H37 Ra, Ref 231141 Difco)into the lower back. The emulsion is prepared by the syringe method withtwo syringes connected through a Luer-lock tube. Mice also receive anintra-peritoneal injection of 300 ng of Pertussis Toxin (Ref BML-G100,Enzo Lifescience) diluted in 200 μl PBS. Pertussis Toxin injection isrepeated 48 hours later. Mice are weighed and examined daily forclinical signs of EAE. Food and water are provided ad libitum.

Clinical Evaluation

Animals were assessed for neurological deficits (clinical score) andweighed daily. The clinical scoring scale is as follows; 0=no signs;0.5=distal limp tail; 1=complete tail paralysis; 1.5=hind limb weakness;2=unilateral partial hind limb paralysis; 2.5=bilateral partial hindlimb paralysis; 3=complete bilateral hind limb paralysis; 3.5=fore limbweakness and complete bilateral hind limb paralysis;4=quadriplegia/moribund; 5=death from EAE.

Results: Assessment of Treatment with Dimethyl Fumarate in Combinationwith Pioglitazone in Form of its Hydrochloride

Forty female C57BL/6 mice aged 8-9 weeks were immunized according to theEAE protocol described in the methods section. Mice were assorted into 4different treatment groups (n=10) and received treatment with HPMC0.5%/Tween20 0.25% (vehicle for dimethyl fumarate) b.i.d. plus Kleptose20% (vehicle for pioglitazone) q.d., dimethyl fumarate 60 mg/kg b.i.d.plus Kleptose 20% q.d., pioglitazone 10 mg/kg q.d. plus HPMC0.5%/Tween20 0.25% b.i.d. or dimethyl fumarate 60 mg/kg b.i.d pluspioglitazone 10 mg/kg q.d. For simplicity, the vehicle treatments werenot mentioned in graph legends and the groups above were named ascontrol, dimethyl fumarate 60 mg/kg bid, pioglitazone 10 mg/kg q.d ordimethyl fumarate+pioglitazone, respectively. Drug treatment started atday 0 post-immunisation. As shown in FIG. 1A, immunization of C57BL/6mice with MOG35-55 induces locomotor disability with the clinical signsarising around day 9 post-immunisation.

The effect of the combination (dimethyl fumarate+pioglitazone) treatmentsignificantly reduced average daily clinical scores (FIG. 1A). Thecombination efficacy was more pronounced and statistically differentfrom the effect of individual treatments. Suppression ofinflammation-induced cachexia acts as a reliable marker of treatmentbenefit. Combination treatment (dimethyl fumarate+pioglitazone)treatment significantly improved body weight in comparison to vehicle orsingle drug treatments (FIG. 1B).

The effect of drug treatment on the prevalence of disease is analysed onFIG. 2. The onset of disease is defined at the point each mouse firstexhibit a clinical score ≧1. FIG. 2A depicts a Kaplan Meier analysisshowing that control group mice start developing EAE from day 9 withcomplete susceptibility by day 14 post-immunisation. The combinationtreatment with dimethyl fumarate+pioglitazone shifted the EAE onsetcurve. Not all animals treated with the drug combination developed signsof disease until the termination of the experiment i.e. day 22post-immunisation. The effect of the combination treatment wasstatistically different not only in comparison with the control group,but also in comparison with each of the drugs dosed alone. FIG. 2B is adifferent representation of the same data. On average, mice treated withvehicle, dimethyl fumarate or pioglitazone alone indistinctly exhibitedfirst clinical signs of disease around day 12-13 post-immunisation,whereas in the combination group the average onset of EAE was around day17 post-immunisation. The effect of the combination treatment was againstatistically different from and more potent than the other treatedgroups. This data shows that combination treatment results in asynergistic treatment effect which is not observed by individualtreatments.

Gastrointestinal changes including haemorrhage are known side-effects ofdimethyl fumarate treatment. Combination treatment and dimethyl fumaratealone treatment resulted in similar hyperplasia of the macrovilosity ofthe stomach. There was no worsening of symptoms with combinationtreatment. Representative images of the stomach of mice chronicallytreated for 22 days with dimethyl fumarate, pioglitazone or theirvehicles are shown in FIG. 3 to demonstrate some of these observations.Importantly, the synergistic efficacy discussed in the previousparagraphs was not associated with increased gastrointestinal adverseevents.

BRIEF DESCRIPTION OF THE FIGURES

FIGS. 1A-1B: Combination treatment with dimethyl fumarate+pioglitazoneis significantly more efficacious than each individual drug asstand-alone treatments or treatment with vehicle on mean clinical scoresand also on body weight changes associated with disease. Averageclinical scores (A) and percentual body weight changes (B) of MOG35-55mice treated with vehicle, dimethyl fumarate, pioglitazone or acombination of both drugs from day O-post immunisation. Kruskal-Wallis(non-parametric ANOVA) with Dunn's multiple test correction was appliedin A and Student's t-test in B. Horizontal bars represent P<0.05 where λcompares combination treatment versus vehicle; If combination treatmentversus dimethyl fumarate and Φ combination treatment versuspioglitazone.

FIGS. 2A-2B: Combination treatment with dimethyl fumarate+pioglitazonecauses a delay on the onset of disease in comparison with eachindividual drug as stand-alone treatments or treatment with vehicle.Kaplan Meier analysis of the disease prevalence curves (A) and averageday of onset of disease (B) of MOG35-55 mice treated with vehicle,dimethyl fumarate, pioglitazone or a combination of both drugs from dayO-post immunisation. The onset of disease was defined as the day micefirst exhibit a clinical score ≧1. Gehan-Breslow-Wilcoxon test wasapplied in A and Kruskal-Wallis followed by Dunn's multiple testcorrection in B. Horizontal bars represent P<0.05 where X comparescombination treatment versus vehicle; Ψ combination treatment versusdimethyl fumarate and Φ combination treatment versus pioglitazone.

FIGS. 3A-3E: Alteration in the macroscopical appearance of the stomachof mice chronically treated with dimethyl fumarate, but not withpioglitazone or vehicle. Forty C57BL/6 mice immunized with MOG35-55 andtreated by oral gavage for 22 days with a combination ofHPMC0.5%/Tween20 0.25% b.i.d. plus Kleptose 20% q.d. (A), dimethylfumarate 60 mg/kg b.i.d. plus Kleptose 20% q.d (B), pioglitazone 10mg/kg q.d. plus HPMC 0.5%/Tween20 0.25% b.i.d. (C) or dimethyl fumarate60 mg/kg b.i.d plus pioglitazone 10 mg/kg q.d. (D). An additional groupof five mice were sham-immunized (emulsion without MOG35-55) and treatedwith HPMC0.5%/Tween20 0.25% b.i.d. plus Kleptose 20% q.d. (E).Throughout the length of the experiment three mice were eithersacrificed due to humane end-points or succumbed to disease. Theforty-two remaining animals were euthanized under pentobarbital terminalanesthesia, the right atrium of the heart was incised and mice wereperfused with 4% paraformaldehyde through the left ventricle. Thestomach of each mouse was dissected by a transection of the proximalsegment of the oesophagus and the duodenum then cut open via alongitudinal incision through the longest possible axis linking theremaining stretch of duodenum and the Fundus. Each piece was washed withphosphate buffered saline and open-mounted. The images shown are fromone representative mouse from each group. Note the normal appearance ofstomachs of all groups of mice that were not exposed to dimethylfumarate (A, C, E) and the seemingly pathological increase inmacrovilosity of the stomachs of groups B and D that were treated withdimethyl fumarate as stand-alone or combination treatment withpioglitazone, respectively, giving them a thickened and rugousappearance.

I claim:
 1. A pharmaceutical composition comprising a glitazone and afumaric acid monoalkyl ester and/or fumaric acid dialkyl ester and,optionally, one or more excipients.
 2. The pharmaceutical compositionaccording to claim 1, wherein the fumaric acid dialkyl ester is selectedfrom dimethyl fumarate or diethyl fumarate and the fumaric acidmonoalkyl ester is selected from monomethyl hydrogen fumarate ormonoethyl hydrogen fumarate.
 3. The pharmaceutical composition accordingto claim 1, wherein the glitazone is pioglitazone or rosiglitazone. 4.The pharmaceutical composition according to claim 2, wherein the fumaricacid dialkyl ester is dimethyl fumarate.
 5. The pharmaceuticalcomposition according to claim 1, wherein said pharmaceuticalcomposition comprises a solid oral dosage form.
 6. The pharmaceuticalcomposition according to claim 1, wherein the fumaric acid dialkyl esteris selected from dimethyl fumarate or diethyl fumarate and the fumaricacid monoalkyl ester is selected from monomethyl hydrogen fumarate ormonoethyl hydrogen fumarate, the glitazone is pioglitazone orrosiglitazone and said pharmaceutical composition is an oral dosageform.
 7. The pharmaceutical composition according to claim 6, whereinsaid fumaric acid dialkyl ester is dimethyl fumarate.